MARCH 2019 Journal of the International Society of Air Safety Investigators

Air Safety Through Investigation JANUARY-MARCH 2019 Journal of the International Society of Air Safety Investigators

ISASI Holds 2018 Seminar in Dubai, UAE page 4

ISASI Kapustin Scholar- ship Essay—Big Data: Thinking Big for Aircraft Accident Prevention page 11

ISASI Presents Capt. Mohammed Aziz with 2018 Jerome Lederer Award page 14

EASA Involvement in Safety Investigations page 17

Investigating Our Future page 22

ISASI International Council Conducts Semiannual Meeting page 26 CONTENTS Air Safety Through Investigation Journal of the International Society of Air Safety Investigators FEATURES Volume 52, Number 1 Publisher Frank Del Gandio 4 ISASI Holds 2018 Seminar in Dubai, UAE Editorial Advisor Richard B. Stone By J. Gary DiNunno, Editor, ISASI Forum—Society members from all over the world Editor J. Gary DiNunno gathered in Dubai, the United Arab Emirates, from Oct. 30 to Nov. 1, 2018, for ISASI’s 49th Design Editor Jesica Ferry international accident investigation and prevention conference to listen to technical pres- Associate Editor Susan Fager entations, conduct ISASI business, and network with colleagues. ISASI Forum (ISSN 1088-8128) is published quar- 11 ISASI Kapustin Scholarship Essay—Big Data: Thinking Big for terly by the International Society of Air Safety Investigators. Opinions expressed by authors do Aircraft Accident Prevention not necessarily represent official ISASI position By Ian Low, University of New South Wales, 2018 ISASI Rudolf Kapustin Memorial Schol- or policy. arship Recipient—The author examines how analyzing “big data” can be useful in accident prevention and can assist in the decision-making process for flight crews thereby incorpo- Editorial Offices: Park Center, 107 East Holly Ave- rating previously unknown or seemingly unrelated factors that contribute to accidents. nue, Suite 11, Sterling, VA 20164-5405. Telephone 703-430-9668. Fax 703-430-4970. E-mail address, 14 ISASI Presents Capt. Mohammed Aziz with 2018 Jerome [email protected]; for editor, jgdassociates@ starpower.net. Internet website: www.isasi.org. Lederer Award ISASI Forum is not responsible for unsolicited By J. Gary DiNunno, Editor, ISASI Forum—ISASI conveys its highest recognition for air manuscripts, photographs, or other materials. safety investigation and prevention, the Jerome F. Lederer Award, to Capt. Mohammed Aziz Unsolicited materials will be returned only if for a lifetime of promoting air safety through investigation. submitted with a self-addressed, stamped enve- lope. ISASI Forum reserves the right to reject, 17 EASA Involvement in Safety Investigations delete, summarize, or edit for space con- siderations any submitted article. To facilitate By Mario Colavita, Safety Investigation and Reporting Section Manager, European Aviation editorial production processes, American Eng- Safety Agency—The author reviews EASA’s 2018 efforts to regulate, certify, and standardize lish spelling of words is used. air accident investigations that involve state investigative authorities within the agency’s jurisdiction. Copyright © 2019—International Society of Air Safety Investigators, all rights reserved. Publica- 22 Investigating Our Future tion in any form is prohibited without permis- By Nat Nagy, Executive Director of Transport Safety, Australian Transport Safety Bureau— sion. ISASI Forum registered U.S. Patent and The author outlines the ATSB’s efforts to be “future ready” by theorizing what kind of exper- T.M. Office. Opinions expressed by authors do tise might be needed, what new forms of data might be required, and how the bureau might not necessarily represent official ISASI position or policy. Permission to reprint is available upon communicate in the future to interested parties. application to the editorial offices.

26 ISASI International Council Conducts Semiannual Meeting Publisher’s Editorial Profile: ISASI Forum is print- By J. Gary DiNunno, Editor, ISASI Forum—The Society’s top officers, councilors, and commit- ed in the United States and published for profes- tee chairs gather prior to ISASI 2018 for their semiannual business meeting. sional air safety investigators who are members of the International Society of Air Safety Inves- tigators. Editorial content emphasizes accident investigation findings, investigative techniques and experiences, regulatory issues, industry ac- DEPARTMENTS cident prevention developments, and ISASI and 2 Contents member involvement and information. 3 President’s View Subscriptions: A subscription to members is pro- 28 News Roundup vided as a portion of dues. Rate for nonmem- 30 ISASI Information bers (domestic and Canada) is US$28; Rate for 32 ERAU Student Selected for Robertson/ISASI Fellowship nonmember international is US$30. Rate for all libraries and schools is US$24. For subscription information, call 703-430-9668. Additional or replacement ISASI Forum issues: Domestic and Canada US$4; international member US$4; domestic and Canada nonmember US$6; interna- ABOUT THE COVER tional nonmember US$8. ISASI President Frank Del Gandio, right, presents the 2018 Jerome F. Lederer Award to Capt. Mohammed Aziz during the Society’s Awards Banquet.

INCORPORATED AUGUST 31, 1964

2 • January-March 2019 ISASI Forum PRESIDENT’S VIEW

TWO THINGS AN INVESTIGATOR MUST HAVE: INDEPENDENCE AND INTEGRITY. INDEPENDENCE TO DO THE WORK WITHOUT OUTSIDE INFLUENCE OR PRESSURE…. INTEGRITY, WITHOUT IT, TRUE PROGRESS IN ACCIDENT INVESTIGATION AND PREVENTION IS NOT POSSIBLE.

WHAT AN ISASI TREASURE!

go-team tance when I had questions or ter of ceremonies for a memo- doing sought guidance. rial dedication at the National major Prior to 2000, ISASI rented Museum of the United States cata- office space in Sterling, Virgin- Air Force at Wright-Patterson strophic ia. The landlord was raising Air Force Base in Dayton, Ohio, acci- the rent, and the new lease to honor of the 61st Fighter dents would have massive increases Interceptor Squadron and around for the next few years. Tom has served for many years as the and I discussed the possibility a volunteer senior docent for world. of ISASI buying a condomini- visitors to the National Air and In his um to establish a new Society Space Museum in Chantilly, career, headquarters. Tom found a vi- Virginia, and trained other vol- Tom was able unit, and ISASI purchased unteers to become docents. involved the condo. Over the years, this During Tom’s tenure as in more purchase has been a major ISASI treasurer, he spent much than 100 cost savings for ISASI and has time and effort to obtain ISASI accident even generated revenue from tax-exempt status from the om McCarthy, an ISASI investigations and was the IIC renting office space to other U.S. federal government and Life Member, started on most. He’s responsible for occupants. The condo is now then subsequently from the his aviation career many safety recommendations worth more than twice what state of Virginia government. Twhen he joined the U.S. that have improved aviation ISASI paid for it. Tom became Tom’s contributions to ISASI Air Force on Feb. 15, 1951. He safety worldwide. the plumber, electrician, win- and aviation safety are truly was a fighter pilot flying the Tom joined ISASI in 1981 dow washer, and performed monumental, and the mem- F-106 Delta Dart with the 61st and was a member of the ISASI other work to help maintain bership is eternally grateful. Fighter Interceptor Squadron Membership Committee before the new unit. We wish Tom the best of stationed in Minot, North Da- becoming committee chair In 2007, ISASI presented health and much happiness in kota, USA. In the early 1960s, in 1994—a position he held Tom with its highest recog- his retirement. He is now living his commander appointed until recently. In 1994, Tom nition for lifetime efforts to the good life in Florida. him the squadron flight safety also accepted the position of improve air safety through officer, and he’s been involved Nominating Committee chair. investigation—the Jerome F. in aviation safety ever since. In 1995, he agreed to assume Lederer Award. In accepting In March 1973, Tom retired the remainder of a term for this award, Tom noted that he from the Air Force as a lieuten- ISASI treasurer, was elected to believes there are “two things ant colonel. Shortly after re- the position in 1996, and con- an investigator must have: tiring, Tom accepted employ- tinued to hold that office until independence and integrity. ment with the U.S. National October 2012. In 1996, Tom Independence to do the work Transportation Safety Board as convinced me to become ISASI without outside influence or an investigator in the New York secretary—a position I held for pressure…. Integrity, without field office and subsequently one two-year term—and then it, true progress in accident transferred to the Washington, to become ISASI president in investigation and prevention is Frank Del Gandio D.C., office to be an investi- 1998. He was always ready to not possible.” ISASI President gator-in-charge (IIC) of the offer sound advice and assis- Tom recently served as mas- January-March 2019 ISASI Forum • 3 ISASI HOLDS 2018 SEMINAR IN DUBAI, UAE

ore than 300 delegates, guests,M and companions from 46 countries—a new record for states represented—gathered at the Intercontinental Hotel in Dubai, United Arab Emirates (UAE), Oct. 30–Nov. 1, 2018, for ISASI’s 49th annual international accident investigation and prevention ISASI 2018 participants attend the President’s Reception on the hotel patio. conference. The theme for ISASI 2018 was “The Future of Aircraft Accident Investi- and techniques unique to military gation.” air operations. Civilian air safety personnel had two options: a Tutorials and the President’s morning session on recognizing Welcome Reception metal fatigue issues at an accident On Monday, October 29, more than site or an all-day multipresenta- 100 safety and accident investigation tion session on future develop- representatives participated in three ments and challenges to air safety preseminar tutorial programs cover- investigation. ing military and civilian aviation safety That evening, tutorial and issues. Military air safety representatives seminar participants were invited attended an all-day session that covered to the President’s Reception—a a wide variety of investigation and safety welcoming gathering held outside Photos: J. Gary DiNunno issues, including case studies of specific on the hotel patio. This event is ISASI President Frank Del Gandio welcomes ISASI military air safety investigations and tools an opportunity to greet longtime 2018 participants to Dubai for the Society’s 49th friends and colleagues and to annual seminar. 4 • January-March 2019 ISASI Forum ISASI HOLDS 2018 SEMINAR IN DUBAI, UAE BY J. GARY DINUNNO, EDITOR, ISASI FORUM

meet new air safety professionals from all formed a sovereign, federal state. over the world. “For North Americans, the land area of ISASI 2018 Opens with a Flourish the UAE is comparable to South Carolina Speaking to a packed crowd in the Inter- or Maine; for Europeans, it is comparable continental Hotel ballroom, Moderator to Austria; and for Asians, it is compara- Mohammed Aziz, Middle East North ble to Japan’s northern island of Hokkai- Africa Society of Air Safety Investigators do. (MENASASI), welcomed delegates and “The changes that have occurred since officials to Dubai for ISASI 2018 and the UAE was founded have been breath- introduced Society President Frank Del taking. To appreciate the change, just Gandio for his traditional opening pres- look around the city here. In 1971, this entation. region was sparsely populated with sev- Del Gandio provided a short history eral relatively small port cities, including MENASASI President Ismaeil Al Hosani of the region. He said, “For those who Dubai. Today, the city is home to more welcomes delegates and guests to Dubai are not from this region of the world, than 3 million. and provides an outline of air safety permit me to offer a brief tutorial on the “For more than three decades follow- investigation in the UAE. UAE. The UAE was formed in December ing independence, oil and international 1971 as a federal state of seven emirates: finance drove the national economy. short time into a major international Abu Dhabi, Ajman, Dubai, Fujairah, Though the prosperity of the UAE still is player and into a rich country, with one of Ra’s al Khaymah, Sharijah, and Umm significantly affected by energy, the UAE the world’s highest GDPs per capita.” (See al-Quwaun. The various emirates have has worked hard to diversify its economy “President’s View,” ISASI Forum, October– long been self-governing; but beginning by making major investments in infra- December 2018, for more of Del Gandio’s in the 1820s and culminating in 1853, the structure, health care, education, tourism, opening comments.) seven emirates plus Oman, Bahrain, and business, and—not coincidentally for an Ismaeil Al Hosani, president of Qatar entered a series of treaties with the organization like ISASI—aviation. Those MENASASI, the host society, welcomed UK and became British ‘protectorates’ efforts were accelerated in response all participants and companions to the but continued to self-govern. When the to the international banking crisis and UAE and Dubai. He noted that in the UAE, UK announced its intention to terminate falling oil prices in 2008–2009. In short, the Air Accident Investigation Sector its treaty in 1968, seven of the emirates the UAE has transformed itself in a very (AAIS) investigates aircraft accidents and

January-March 2019 ISASI Forum • 5 incidents. He observed, “AAIS is still very picture. In comparison, today’s solid-state time to double-check the facts or you young.” The agency was established in recorders produce a huge amount of lose; a need to feed websites, TV, or radio; 2012 and now has a director, eight inves- data with a high sampling rate—3,500 a need to grow and keep a large audience; tigators, one technical assistant, and four parameters, 1,024 words per second—and and a need to generate controversy. administrators. offer the capability for almost “real time” “Who are these people? They are gen- “Most of our activities,” Hosani said, identification of the big picture. And erally self-appointed experts, bloggers, “involve investigation of accidents and tomorrow’s data sources may include social media participants, journalists, incidents occurring to commercial trans- digital flight data recorder traces, replay and politicians who all want to be a part port aircraft.” He pointed to two notable devices, video, and data streaming from of the buzz society and gain the visibility accident investigations as examples: a an aircraft. they believe the buzz provides them,” said B-747 lithium battery fire accident in “What about other sources that are Malinge. “The buzz loves an information September 2010 and a B-777 go-around not sent from the aircraft but are publicly void—simply because a void allows space accident in August 2016. “The UAE has available?” he asked, noting that near- for speculation. The only proven means a large fleet of helicopters,” said Hosani, ly all passengers on an aircraft or in or to minimize speculation is to fill the in- “and helicopter incidents and accidents near an airport terminal have video and formation void. For future investigations, feature significantly in our workload.” He photo capability on their smartphones starting today, accident investigation added that other investigations involve and can instantly link their data to global boards should communicate the big pic- recreational aircraft and hot air balloons. social media platforms. “With all the ture as soon as possible. Experience tells AAIS “has a modern flight recorder lab,” data collection and information sharing us that this is the only effective means to Hosani observed, “where we can down- means available today and even more in minimize the buzz. load and analyze data from almost 100 the future, we need to be ready for nearly “As air safety investigators, we face a percent of the flight data recorders in use real-time and open investigations as we large paradox about the power of infor- today.” He noted that the lab is continual- face millions of self-appointed investiga- mation sharing,” Malinge noted. “While ly improving to ensure that investigators tors among the public—worldwide—who unsubstantiated information sharing may have use of the latest computer software interfere with our investigations, we still and hardware. recognize that data sharing is one of the Hosani said AAIS is engaged in inter- most powerful tools we have to prevent national safety investigation activities accidents through identifying trends and through participation in International examining prior events. But this requires Civil Aviation Organization (ICAO) work- trust among all interested parties. ASIAS ing groups and ISASI and MENASASI [the U.S. Aviation Safety Information corporate membership. He remarked that Analysis and Sharing program], for AAIS assists other regional state inves- example, took eight to 10 years to define tigation authorities with their investiga- governance and obtain a cruise level. tions and provides training to state and Why so long? Participants feared punitive industry organizations. In addition, AAIS action. Where there is no trust, there is has established memorandums of under- no effective data sharing. A day will come standing with many regional and interna- when an accident investigation board will tional air safety investigation entities. want to gain access to data from these information sharing systems as part of Opening Keynote Address an investigation. If yes, think twice about Yannick Malinge, senior VP and chief such an action—it could indeed kill the product safety officer, Airbus, provided trust such systems require if the informa- the opening session keynote address. tion is used in an accident context. Yannick Malinge, Airbus, provides the He discussed accident investigation opening day keynote address. “Finally, investigating systemic issues is information, data sharing, and commu- important,” observed Malinge. “As expe- nication in the world of instant news and expect instant publicity and information rienced air safety professionals, we have social media and the need to investigate sharing. all participated in investigations with systemic issues. Regarding the accident “This sizable population leads to our factors that we’ve seen before—many information aspect, he noted that the real next challenge—the buzz society with all accident types and their typical contrib- starting point for air safety investigation its inherent issues descending on an air- uting factors are usually well known, and is accident data, but the questions for craft accident,” Malinge observed. “Think their mitigating actions are also known future investigators must be what will about the speed of information flow in to- from a technical or operational view. So the data sources be and who will have day’s world and the consequences of hav- is there something we need to investi- access? ing a huge number of nonaviation people gate differently to ensure we address the Looking at data sources, Malinge ob- who feel the need to be the first to record underlying factors that lead to the ‘déjà served that early “black boxes” produced any event for a buzz feed regardless of any vu’ syndrome? a metal sheet with a limited number of validation process. What seems to count “For future accident investigation, is parameters and reduced sampling rate in today’s world is the need for speed of it not time to ensure we address safety and that it took time to identify the big communication, not the accuracy—no governance aspects—to investigate all

6 • January-March 2019 ISASI Forum SMS ingredients? Is it not time, while keeping typical accident catego- ISASI 2018 Technical Program ries (LOC, CFIT, etc.), to also identify cluster factors according to SMS elements to make sure underlying factors are well established so they Monday, Oct. 29, 2018 Tutorial 1: can be addressed? Is it also time for accident investigation boards to set Basic Failure Analysis up their own SMS?” Malinge asked. 900–1300 “Failure Mode Identifications at the Accident Site”—Andy McMinn Tutorial 2: Future Developments and Challenges to Investigations 900–930 “Overview and Introduction”—Anthony Brickhouse, ERAU 930–1030 “Improving Safety with Few Accidents Occurring”— Bertrand de Courville, Air France, Ret. 1045–1145 “Augmented Reality in Future Investigations”— Chris Lowenstein, Sikorsky 1145–1245 “Current and Future Challenges of Recorded Data”—Ismail Kaskkash, KSA AIB 1400–1530 “Selecting and Training the Next Generation of Air Safety Investigators”—Keith McGuire, NTSB, Ret., and Mohammed Aziz, Middle East Airlines, Ret. 1545–1645 “Artificial Intelligence in Accident Notifica- tion”—Abdulla Mohammed Al Blooshi, Dubai Civil Aviation Authority Tutorial 3: Military Aircraft Accident Investigation 900–1600 “Overview and Introduction”—Jim Roberts, UK Defence AIB The Nigerian accident investigation board delegation to ISASI 2018 poses “EA-6b Ejection Mishap—No Second Thoughts”—Chris Field, outside the hotel during a break in the proceedings. From left are Olupon- Boeing Air Safety Investigations (U.S.) mile Joseph Alao; Abdulsalam Abuakar Sadik; Dayyabu Mustapha Danraka; “Selected Case Studies of the Use of S&T to Assist Investi- Akinola Olateru, board commissioner; Simon Okwaokei, board consultant; gations”—Sqd. Ldr. David Palmer, Australian Defense Fight and Bartholomew Shoshan. Safety Bureau “Investigating a Fatal Mishap of a Chartered Airplane Perform- “Thank you, and I wish all of you a good ISASI 2018.” ing a State Mission from Malta”—Brdg. Gen. Bruno Caitucolli, BEA “Update European Investigators Operating Guidance (IOG)”— More Introductions Lt. Col. Weidemann, Aviation Safety Brundeswehr (Germany) Before the formal technical presentations began, Del Gandio announced “Mishap Case Study–Denmark”—Lt. Col. Martin Aarestrup, Danish MAAIB that recent elections returned all incumbent Society officials to their “Australia’s System for Classification and Tracking of Aviation posts for the next two-year term. He introduced Vice President Ron Safety Events”—Australian Defense Flight Safety Bureau “Open Forum, How Your Organization Captures, Tracks, and Implements Safety Recommendations from a Mishap”—Jim Roberts, Boeing, and Olivier Ferrante, BEA

Tuesday, Oct. 30, 2018 0830 Opening Moderator—Mohammed Aziz, Middle East Airlines, Ret. Welcome—Frank Del Gandio, ISASI President Welcome—Ismaeil Al Hosani, MENASASI President Introduction of the Kapustin Scholars 0900 Keynote Address—Yannick Malinge, Airbus 0930 “Timeliness of Investigations”—Marcus Costa, ICAO 1000 “EK521 Boeing 777-300 Accident Investigation Process”— Fazal Aibaksh, GCAA 1100 “Service Providers Safety Investigations and the Link to the State Safety Program”—Richard Davies and Paula Gray 1130–1200 The recent ISASI election returned all of the incumbent international “Mars Journey, Climb Phase”—Ismail Kashkash, KSA AIB officers to another two-year term. From the left are Bob MacIntosh, Frank 1330 Del Gandio, Ron Schleede, and Chad Balentine. Afternoon Session Moderator: Salah Mudura—MENASASI “MH370—Multiple AUVs in Search Mode”—Oliver Plunkett Schleede, Treasurer Bob MacIntosh, and Secretary Chad Balentine. and Trevor Hughes, Ocean Infinity Del Gandio then recognized all of the ISASI councilors and society 1400 presidents attending the seminar and introduced Professor Anthony “Challenges of Investigating an Experimental Unmanned Demonstrator Aircraft Incident”—James G. Buse and Jeffery J. Brickhouse, Embry–Riddle Aeronautical University and coordinator of Kraus, Boeing ISASI’s Outreach and Mentoring Program, and Marcus Costa, chief AIG, 1430 ICAO. As chairman of the ISASI Rudy Kapustin Scholarship Committee, Kapustin Scholar Presentation: “Off the Accident Site and into the Hangar: Incident Investigation Using Structural Health Balentine then introduced the four recipients of the Kapustin 2018 schol- Monitoring”—Katrina Ertman, Delft University of Technology arships: Katherine Ertman, Delft University, the Netherlands; Avery Katz, Embry–Riddle Aeronautical University, Florida, USA; Ian Low, University (Continued on page 29)

January-March 2019 ISASI Forum • 7 of New South Wales, Sidney, Australia; and Nicolette Meyer, Embry–Riddle Aero- nautical University, Florida, USA. During ISASI 2018, participants donated more than $3,500 to the 2019 scholarship fund. Following Tuesday’s technical presentations, regional and national societies held business meetings. That evening, seminar participants and their guests boarded buses to travel to the center of Dubai where they boarded a two-deck dhow for a buffet dinner and a cruise to see the sights along Dubai Creek.

ISASI 2018, Day Two Morning session Moderator Abdulelah O. Felimban, Accident Investigation Board, KSR, opened the gathering and introduced the speakers for the first and following technical presentations. Prior to the lunch break, ISASI held a short ISASI Secretary and Kapustin Scholarship Committee Chairman Chad Balentine, left, business meeting to discuss the Society’s introduces all of the 2018 scholars to the seminar participants. finances, membership status, and future projects. Following lunch, Afternoon Moderator Ibrahim Al Koshy, Saudia Airlines, introduced additional technical presentation speakers. At the end of the day, ISASI committees and working groups met to discuss ongoing and future projects. Seminar participants then gathered for the ISASI Awards Banquet on the hotel patio and enjoyed traditional and modern dancing and a wide variety of international cuisine.

ISASI 2018, Day Three MENASASI board members conduct a short business meeting following Tuesday’s final Morning Moderator Mark Burtonwood, technical presentation. Emirates, opened the third day of ISASI 2018 with the introduction of Graham Braithwaite, Cranfield University, who gave the final keynote address. Braithwaite said, “I would like to thank the seminar organizers for inviting me to be today’s keynote speaker. I was unable to attend the first day, but I heard great Seminar participants and guests enjoy a things about the presentations. I thor- buffet dinner while watching the evening sights of Dubai. oughly enjoyed yesterday’s sessions. “I do talk a bit about the future, and the great thing about that is that you cannot be wrong now. You can only be wrong later. I want to talk about how we prepare investigators for what is a really exciting and rapidly developing aviation transformation. As a university, we do not just get involved in training accident investigators, we also get involved in a whole range of areas, including designing things in which we may become involved in the future. “For example, we did some work with 8 • January-March 2019 ISASI Forum tric-powered, luxury, vertical takeoff and landing vehicle that I hope to see flying within a very short time,” Braithwaite said. “The concept debuted at the Farn- borough Air Show this year. We hope to have a flying prototype within two years for the next Farnborough. “The question is how do we integrate all this change into the aerospace system in a safe manner?” asked Braithwaite. “First, when we think about what future aviation might really need, we get excited about Moderator Abdulelah O. Felimban, this type of airplane. What we also see is Moderator Mark Burtonwood, Emirates, Accident Investigation Board, KSA, opened a need—a need to move people and cargo opens the third day of ISASI 2018. the Wednesday morning session. around safely, efficiently, and to minimal- recognize that transport is part of a Boeing, NASA, and the U.S. Air Force on ly impact the environment. We [the air working infrastructure. In this process, a blended-wing concept aircraft,” Braith- transport industry] have not been so good there is a lot of emphasis on the user-cen- waite noted. “We designed a prototype at the latter. What we are really delivering tric experience—you, the traveler, can for a UAV rather than one that would is an ability or a service. We are delivering tailor your journey to whatever you want be flying passengers. Our new research people and cargo to a particular destina- in terms of demand. We look at it in a way center at Cranfield is a collaboration tion, at a particular cost, at a particular that can be done in the future. among Airbus, Rolls Royce, and the UK time, and at a certain level of safety. “So here is a challenge that the Euro- government where we are looking at “So how do we fit into where air trans- pean community is examining through aerospace integration. And the concept port is heading or where this concept this program: what will flying look like in of integration goes far beyond putting the of an ability is heading? This is quite 2050? One goal is to have 90 percent of physical engineering systems together. It significant to you as safety investigators,” travelers in Europe be able to complete actually gets into trying to change more Braithwaite observed. “We are working their journey, door-to-door, within four radically the concept of what we might within the UK, among the big carriers, hours,” Braithwaite noted. “Europe may look at as aircraft. You get to a point manufacturers, research councils, and be smaller next year so that becomes a lit- where you must not only think about how universities, through a system called tle easier. Now, if I budget my travel time the aircraft looks different, but also how the catapult. Now in case you think we from North Hampton, my journey by air the infrastructure must look different. are going to fire people and cargo from in Europe starts with two hours to get to “Again, in a collaboration between catapults, what the catapult system is all the airport and two hours to get through Cranfield University and our offshoot, about is how we take transformational the airport. So to have my flight arrive on Aerospace Solutions, and two brands ideas and turn them into reality. The UK time at its destination is basically irrel- you may have heard of—Rolls Royce and has one such program called Transport evant because it is the beginning of my Aston Martin—there is the Volante Vision Systems, and it recently merged with journey that slows me down. However, aircraft, which is a three-seat, elec- another called Smart Cities because we what if ticketing says instead of driving, my taxi is already booked, the train you are getting on is running on time, the parking you were paying for has been transferred into this journey, and you will arrive more quickly this way than any other way. That’s a user-centric experience in which your journey managed everything for you—including the ticketing and so on. But as soon as we start doing things

Mohammed Abdul Bari, Air Accident Investigation Sector, UAE, joins traditional male Professor Graham Braithwaite, Cranfield dancers during the Awards Banquet. University, gives the final keynote address. January-March 2019 ISASI Forum • 9 like this, I must ask what about my a passenger needs to spend in an me as an air safety investigator? The picture that I level of comfort and my level of airport. He said we would really like am trying to paint for you is that future destruction safety? What is the carrier I am now this autonomous vehicle to collect of the current transport environment will be really on for the minibus leg I am starting a passenger from home—we know quite significant, particularly if we think in terms of as part of my journey? where it is. We can security screen in personal mobility,” Braithwaite observed. “We get “Looking at a much bigger com- the vehicle. We can know exactly the nervous when people get excited about the possi- munity, we have to provide a journey size and weight of the baggage. And bility of flying taxis. We try to remind everyone that that is safe and also resilient. Airport we can start the in-flight entertain- these need to be at least 10 times safer than traveling capacity in certain parts of the world ment experience on that part of the in a car. Can you imagine going back to your aviation is becoming absolutely critical,” re- journey. Passengers can order the organization and saying what we now need to aim marked Braithwaite. “If the weather duty-free items that will be placed for is a level of safety that is 10 times safer than it is bad or if there is a disruption from in the back of the vehicle that picks currently is in a car? a security concern or something else, them up at the other end. So why “You may want to look at a document that the people face missing their journey do passengers even need to go to International Air Transport Association published and airports run out of capacity to an airport? I don’t know how many about a year ago about what the aviation industry divert aircraft. So some of the chal- people here have had the experience might look like in 2035. They talk about drivers in lenge is to consider that resilience at of being late for their flight or had changes in society, technology, environment, econo- airports impacts what we are doing. other passengers want to cut into my, and politics,” noted Braithwaithe. “Aviation does “In talking to some of the inno- the security line because their flight not exist in a bubble. It exists within the context of vators, they want to disrupt the was at final boarding. Your autono- everything else. So it is entirely correct when we talk current system even more signifi- mous vehicle could do this for you about the electrification agenda—we need access to cantly,” Braithwaite said. “They ask by putting you in the right place at efficient power sources—a power depends upon the why do you need to spend two hours the right time. availability of fuel and water. We are competing for at an airport?” An airline rep said “So you are probably thinking resources while setting ambitious targets about how we think three or four minutes is all what does this all have to do with we become less polluting, more efficient, and serve To celebrate ISASI 2019 being held in the Netherlands, Host Committee this demand for air travel. Chairman Daan Zwart presents ISASI President Frank Del Gandio with a pair of “There are many factors that impact us, includ- wooden shoes. ing where do we find the talent and the people who work in aviation and are attracted to aviation careers? People who have now been in aviation for a long time often say it is not like it used to be,” Braith- waithe remarked. “The job has changed, and there are many other exciting jobs out there with which we compete for talent, particularly in areas such as electrification, digitalization, and artificial intelligence, for example. “So whatever we now think is aviation will start to blur, to change. When we start to talk about drones and UAVs, we are only just beginning to image what people might do with such vehicles. It has not been so long ago when people were talking about developing drones to clean your windows, to deliver your pizza, to deliver an organ for transplant,” said Braithwaite. “There are new players coming into the aviation market. The consumer is increasingly buying products direct from a service provider, and they do not always know who that is. Consumers simply recognize a brand. When we talk about these commercial applications and small drones, you know that regulators across the world are wrestling with how do we govern this? How do we approach that task where these small vehicles do not belong to a big airline where you recover the cost of regulating quite as simply as you might at the moment? So eco- nomics and regulations start to change. By the way, which regulators should cover this? Just because these vehicles fly does that mean they get covered by a civil aviation authority? What about all the communication factors? There is a lot of data streaming involved and other regulators who now start to get (Continued on page 30) 10 • January-March 2019 ISASI Forum ISASI Kapustin Scholarship Essay The following article is the second of four essays from the 2018 Kapustin Scholarship winners. The number of scholars selected each year depends upon the amount of money BIG DATA: ISASI members donate annually to the scholarship fund. Details THINKING BIG FOR about scholarship applications and additional information can AIRCRAFT ACCIDENT be found on the ISASI website at www.isasi.org. Application and PREVENTION essay deadlines are mid-April of each year.—Editor By Ian Low University of New South Wales

ig data is a ubiquitous term to- data, 2) cleansing the data, 3) modelling day with an array of applications and analyzing the data, and then finally, across industries. The aviation 4) generating useful information leading Bsector is no different, and big to improved decision-making. Big data data has been used successfully by analytics has been successfully used for some airlines to improve on-time per- predictive maintenance, thereby allow- formance, increase fuel efficiency, and ing users to forecast/predict potential manage maintenance requirements maintenance issues based on historical (Bellamy, 2017). In this essay, it will be data (Gandomi & Haider, 2015). argued that big data can offer much more: a new paradigm for aviation safe- The current approach to accident ty—a proactive, data-focused approach investigations to accident prevention. Accident investigation is an “occupational safety analytical tool” that seeks Demystifying big data to understand the factor(s) that lead Although the precise origins of the to the accident (Salguero-Caparros, term “big data” are uncertain, the first Suarez-Cebador & Rubio-Romero, references to it in academic articles 2015). Accident investigations have were in the late 1990s in the fields of typically been performed through a statistics and econometrics (Diebold, process of hypothesis testing, in which 2012). Big data can be defined as “large a hypothesis is first proposed, followed volumes of high velocity, complex, by the collection of evidence, and finally and diverse types of data that require supporting or rejecting the hypothesis advanced techniques and technologies (Huang et al., 2018). Ian Low to enable the capture, storage, distribu- According to the International Civil tion, management, and analysis of the Aviation Organization (ICAO), the prin- information” (TechAmerica Founda- ciple purpose of investigations is “the Ian Low is a final year student com- tion’s Federal Big Data Commission, prevention of accidents and incidents” pleting his bachelor of aviation (man- 2012, p. 10). (ICAO, 2016, p. 16). In this regard, ac- agement) degree at the University of Data is only valuable if insights can cident investigators, past and present, New South Wales, Australia. After be extracted and used to aid in deci- have made significant contributions graduation, he intends to undertake the sion-making (Gandomi & Haider, 2015). to improving aviation safety. Through postgraduate Aviation Honors Program Huang, Wu, Wang, and Ouyang (2018) a better understanding of the causal and specialize in aviation safety and proposed that big data analytics could factors behind aviation accidents, the human factors. Ian will then return to his home country of Singapore, where be understood through four distinct aviation sector has been able to respond he is a military helicopter pilot with the processes. In brief, these four processes by developing and implementing safety Republic of Singapore Air Force. include 1) acquiring and classifying the programs to avoid future accidents; January-March 2019 ISASI Forum • 11 ISASI Kapustin Scholarship Essay

for example, crew resource management While accident investigators strive to generation aircraft come into service. training was implemented to address be objective and thorough in their acci- Wyman (2016) predicted that the global failures in interpersonal communication dent investigations, traditional accident fleet could generate 98 million terabytes of (Helmreich & Foushee, 2010). investigation findings are always qualita- data by 2016. Operators have been quick to Although air travel has increased sig- tive (Huang et al., 2018) and contingent on capitalize on this trend for aircraft health nificantly over the past few decades, the the investigators’ training and experience. monitoring and predictive maintenance; number of fatal accidents has decreased; Furthermore, Yodice (1984) suggests that this also provides a valuable opportunity 2017 marked the safest year on record for there are often competing interests, such to extract safety-related data. the commercial aviation sector with zero as tort litigation, the enforcement process, A practical example of how big data fatalities (BBC, 2018). This positive trend and the news media, that could interfere may be used to proactively manage safety can be attributed to the increased reliabili- with the accident investigation. Big data in aviation is utilizing a “Rule of Three” ty of new aircraft designs, and the aviation analysis offers an alternative quantitative principle, similar to that proposed by sector’s addressing of identified failures approach to accident investigation that Hudson and van der in the oil industry. in aviation safety (Helmreich & Foushee, could analyze all available information, Hudson and van der (1998) argued that 2010). not just the factors that are obvious to the criteria for go/no-go decisions often However, with increasingly congested accident investigators; this could result in failed to consider the interaction between airports and skies, aviation accidents will investigators uncovering other accident various factors. In their proposed Rule of inevitably increase unless the accident rate causal factors that may have otherwise Three, major dimensions, such as weather, decreases further (Airbus, 2017). Hence, been overlooked. are broken down into minor dimensions, while the current approach to accident In terms of accident prevention, big such as rain, wind, and lightning. These investigations has been successful thus far, data could also help the aviation sector sub-dimensions are then color coded it is important to innovate and ensure that shift from a traditionally reactive ap- based on their historical contribution to complacency does not set in. One possibil- proach to one that is more proactive and accidents. Dimensions with no direct link ity is leveraging technology advancements forward looking; this is possible due to the to an accident are coded green. Dimen- in data analysis to identify potential safety real-time nature of big data analysis. For sions with a broken link are coded orange, issues and prevent aviation accidents; this example, WayCare, an Israeli technology and dimensions with a direct link are could be achieved by linking the databases company that specializes in transport coded red. Similar to a traffic light, any of accident authorities and airlines around management systems, has conducted its dimension in red halts operation—as do the world. own analysis of road data and claims it three or more dimensions coded orange. is able to predict more than 70 percent The decision criteria, shown in Table 1, The opportunities for big data in acci- of traffic crashes two hours before they would then be applied. The Rule of Three’s occur (WayCare, 2017). It leverages ex- objective is a simple rule-of thumb tool dent investigation isting infrastructure, tapping on existing that is designed to remove the ambiguity Due to the complex and diverse nature real-time data sources such as localized out of decision-making (Hudson & van der, of accidents, accident investigations are weather data, road closures, camera feeds, 1998), which is importantly based on fac- often a long process, sometimes lasting and accidents to make predictive recom- tual information, in this case gleaned from years. The limited number of aircraft mendations with the ultimate objective of using big data. Hence, big data has the investigators also means that safety minimizing road congestions and prevent- potential to improve decision-making, as agencies must prioritize accident cases; ing road accidents. illustrated in the above example. Such data for example, the NTSB has four different The aviation sector is already awash can be extracted from real-time weather categories of accident investigations, with data sensors, and the extent of information, flight schedules and dura- ranging from the lowest priority “C Form data generation is expected to increase tions, crew rosters, and crew composition, Investigation,” which is primarily used for significantly in the future as more new to name a few. data collection and relies on the operator to self-report, to “Major Investigation,” where a full team of accident investi- Table 1. The Rule of Three Decision Criteria (Hudson & van der, 1998) gators is allocated (Sumwalt & Dalton, Number of critical dimensions Action (go/no-go) 2014). Leveraging big data could aid this process by comprehensively analyzing the All green Proceed normally database of accident records to quickly One orange Proceed normally identify trends with previous accidents; it could also pick out plausible accident Two oranges Proceed with caution causal factors, aiding in hypothesis gener- Three oranges Halt operation/reduce problems ation and ultimately the accident investi- One red Halt operations gating process.

12 • January-March 2019 ISASI Forum References

From a safety management Airbus. (2017). A Statistical Analysis of Commercial Aviation Accidents perspective, big data can also (1958-2016). Retrieved from http://www.airbus.com/content/dam/corporate-topics/publications/safety-first/Airbus-Commercial-Aviation-Acci- provide better insights into an dents-1958-2016-14Jun17.pdf. airline’s emerging safety issues. According to the International BBC. (2018). 2017 safest year for air travel as fatalities fall. Retrieved from Air Transport Association (IATA) http://www.bbc.com/news/business-42538053. (2018), in 2017 the accident rate for IATA operational safety audit Bellamy, W. (2017). Data Analytics Driving Efficiency in Commercial Aviation. (IOSA) airlines was almost four Retrieved from http://interactive.aviationtoday.com/data-analytics-driving-efficiency-in-commercial-aviation/. times better than that of non-IO- SA members; IATA members are Diebold, F. (2012). A Personal Perspective on the Origin(s) and Development of required to adhere to high levels "Big Data": The Phenomenon, the Term, and the Discipline, Second Version. PIER of safety standards and maintain Working Paper No. 13-003. Retrieved from http://ssrn.com/abstract=2202843. their IOSA registrations. While this compliance strategy has Gandomi, A., & Haider, M. (2015). Beyond the hype: Big data concepts, methods, worked thus far, IATA has already and analytics. International Journal of Information Management, 35(2), 137-144. doi:https://doi.org/10.1016/j.ijinfomgt.2014.10.007. announced a digital transformation plan that will leverage the Helmreich, R.L., & Foushee, H. C. (2010). Chapter 1 - Why CRM? predictive analytics of big data Empirical and Theoretical Bases of Human Factors Training Crew to improve operational safety; Resource Management (Second Edition) (pp. 3-57). San Diego: its “Six Point Safety Strategy” is a Academic Press. “comprehensive data-driven approach to identify organizational, Huang, L., Wu, C., Wang, B., & Ouyang, Q. (2018). A new paradigm for accident investigation and analysis in the era of big data. Process Safety Progress, 37(1), operational, and emerging safety 42-48. doi:doi:10.1002/prs.11898. issues.” (IATA, 2018) Hudson, P., & van der, G. (1998). The Rule of Three: Situation Awareness in Conclusion Hazardous Situations. Retrieved from https://www.researchgate.net/publication/254507326_The_Rule_of_Three_Situation_Awareness_in_Hazardous_Situa- Big data has already been used tions doi:10.2118/46765-MS. extensively in many industries, providing valuable insights into IATA. (2018). IATA Releases 2017 Airline Safety Performance [Press release]. all facets of operations. In the Retrieved from http://www.iata.org/pressroom/pr/Pages/2018-02-22-01.aspx. aviation sector, it has proved useful in helping airlines improve ICAO. (2016). Aircraft Accident and Incident Investigation (Annex 13 to the Con- operational efficiency and better vention on International Civil Aviation). Retrieved from http://www.emsa.europa. eu/retro/Docs/marine_casualties/annex_13.pdf. manage maintenance requirements. With an increase in air Salguero-Caparros, F., Suarez-Cebador, M., & Rubio-Romero, J.C. (2015). Analysis travel demand, it is important of investigation reports on occupational accidents. Safety Science, 72, 329-336. not to become complacent about doi:https://doi.org/10.1016/j.ssci.2014.10.005. aviation safety. As the amount of data available increases, it is Sumwalt, R., & Dalton, S. (2014). The NTSB's Role in Aviation Safety. Retrieved possible to use this data to from https://www.ntsb.gov/news/speeches/RSumwalt/Documents/Sum- walt_141020.pdf. predict the likelihood of an accident occurring. Importantly, TechAmerica Foundation’s Federal Big Data Commission. (2012). this data can be used by airlines Demystifying Big Data - A Practical Guide To Transforming The Business of to assist in the decision-making Government. Retrieved from https://bigdatawg.nist.gov/_uploadfiles/M0068_ process for crews. Capitalizing v1_3903747095.pdf. on a proven method of decision-making heuristics (i.e., Rule WayCare. (2017). Predictive Insights for Smart Cities. Retrieved from http://waycare-smart-highway.com/#technology. of Three), big data can be used to facilitate more objective crew Wyman. (2016). 2016 MRO Survey. Retrieved from http://www.oliverwyman. decision-making, incorporating com/our-expertise/insights/2016/apr/mro-survey-2016.html. previously unknown or unrelated factors that contributed to Yodice, J.S. (1984). Aircraft accident enquiries – whose interest prevails? accidents. Air and Space Law, 57-60.

January-March 2019 ISASI Forum • 13 ISASI Presents Capt. Mohammed Aziz with 2018 JEROME LEDERER AWARD

BY J. GARY DINUNNO, EDITOR, ISASI FORUM

he International Society of Air Africa region and to promote air safety Safety Investigators, during ISASI investigation studies and training. This 2018, awarded Capt. Mohammed effort helped to establish MENASASI. TAziz with the coveted 2018 Jerome “During his long career as an airline F. Lederer Award in recognition of his pilot (1972–2016),” Del Gandio said, lifetime efforts to promote aviation “Capt. Aziz assumed many managerial safety through investigation. Frank Del positions within Middle East Airlines Gandio, ISASI president, noted during and participated in many industry the award banquet ceremony, which was committees and working groups that held on the hotel patio overlooking a wa- contributed to aviation safety.” He terway leading to the Persian Gulf, that the award “is the highest ISASI honor an aviation accident investigator or safety professional can receive, and Capt. Aziz is most deserving of this award.” Del Gandio remarked that Aziz has stead- fastly worked to improve aviation safety through his investigations, training other safety personnel, flying as an airline pilot, and mentoring others interested in becoming aviation industry professionals. Aziz “was the initiator and focal point for the formation of ISASI’s Middle East North [MENASASI] Africa Society,” Del Gandio declared, and observed that he has been an “air safety investigator and ISASI member since 1994.” Since that time, Aziz has conducted many aviation accident and incident investigations as investigator-in-charge or accredited representative for Lebanon—some of which were shared during past ISASI seminars. Aziz, Del Gandio reported, “contributed to many ISASI seminars and to ISASI Forum on various subjects related to accident prevention, safety management, regional and international cooperation, and safety investigation. He also participated in numerous ISASI working groups and sponsored, through MENA- SASI, two ISASI Reachout seminars—in Beirut, Lebanon, during 2002 and 2016 and helped organize regional ISASI seminars in Dubai; Rabat, Morocco; and Photos: J. Gary DiNunno Saudi Arabia.” As chair of the Arab Air Carriers Organization Safety Committee has been a part of the International Air cil from 2009–2011. He also chaired from 1995 to 2014, Aziz worked dili- Transport Association’s (IATA) IOSA IATA’s Human Factors Working Group gently to increase the numbers of ISASI Oversight Council since that group’s (2004–2005) and was a member of the members in the Middle East and North establishment and chaired the coun- IATA Safety Committee (1993–1996) 14 • January-March 2019 ISASI Forum CAPTAIN program. He started safety bulletins and to continue discussing disagreements MOHAMMED safety newsletters. These are some of the because it’s only through agreement and AZIZ, RIGHT, early achievements of Jerry Lederer. dialogue that we can improve. So if there “I was fortunate enough to meet Jerry is disagreement in a report, we should RECEIVES THE many times. The last time I remember not set it aside and forget about it. The 2018 JEROME was just after the 9/11 attacks. He was fourth problem is public disillusion with F. LEDERER nearly 100 years old. We were discuss- air safety in that our success can lead AWARD FROM ing slides on the aircraft—escape slides to the public misunderstanding that FRANK DEL to evacuate the aircraft. He said that our job is done. In fact, it will never be many years ago he was walking on the completely done, unless we do not look GANDIO, ISASI sidewalk in New York near a playground. for continuous improvement. PRESIDENT. When he saw children playing on the “So let’s look at problems for the slides, he thought, ‘You know—that future. This is done mainly through would be a good idea to put on an air- training. During the seminar, I talked craft.’ This is a brief summary of what he about field investigation. Just like pilots did. losing some of the skills they have today “I was fortunate to work for Middle because they are not ‘flying’ manually East Airlines. Despite all the difficulties anymore, which may result in being un- during the 45 years that I spent as a pilot prepared for the effect of surprise. Much there, we had safety as number one. Even of the loss of control you see today can during war time, safety was number one, be attributed to pilots being surprised. and it's still the priority today. I was also By the time the pilots know what is going fortunate to travel outside the country on, it's too late and the aircraft is gone. of Lebanon to get additional education. So how can we improve this? When we and the IATA Operations Committee Lebanese always supported getting investigate and make recommendations, (1996–1998). continuous education, especially for the we should not say the pilot did some- Del Gandio observed that Aziz, as an improvement of air safety. I was also for- thing wrong or did not have enough International Civil Aviation Organization tunate to be a part of MENASASI. Under time. We need to put our investigations (ICAO)- and IATA-certified instruc- the leadership of Al Hosani and the rest into context of the accident, otherwise tor, contributed in the education and of the board, we were able in five years to what we do will be useless. training of many industry experts over organize local seminars, contributions, a “If a pilot has five seconds to make the years, lectured on safety and aviation magazine, and the seminar you see here a decision about how to recover an management at various universities, today is one such example. So this is aircraft, we should not spend two days and developed many related manuals about the past. deciding what the pilot was supposed and courses. Academically, Aziz earned “Let’s go to the future. What do we to do. We have to put our investigations BA and MA degrees from Beirut Arab want in the future? The theme for ISASI into context. We have to ensure the University, a Ph.D. from the University 2018 is “The Future of Aircraft Accident pilots get training that addresses how of Alexandria, and an MBA in aerospace Investigation.” Most of the presentations to recover a failing aircraft—something from the Toulouse Business School. we heard during the seminar were about simulators can provide. Perhaps simula- Del Gandio concluded that Aziz is a the future of accident investigation. In tors can be used to develop skills for fu- safety professional of the highest degree order to move quickly into the future ture investigators if simulation programs who has consistently served the flying while keeping aviation safe, we have to can show what we see in aircraft today public and the industry through promo- put our fingers on the problems we have and what we see at the accident site. Air- tion of global aviation safety and security today. Some of these problems include craft simulators are justified due to the and is truly worthy of the Jerome F. the misinterpretation or misapplication number of pilots we need to train. What Lederer Award. of rules we have today. We heard a sem- about investigation simulators? Who is Aziz responded, “Thank you, Frank. I inar presenter, Marcos Costa, the head going to fund them? We have among our am really thrilled by the honor. I am even of the Accident Investigation Branch at seminar participants numerous repre- more thrilled for the association with ICAO, disclose that only 32 percent of ac- sentatives from universities that not only Jerry Lederer. For the younger generation cidents result in a final report. And a re- teach air safety investigation and man- who don’t know Jerry, he was born in port is only the first step—it’s like a doc- agement, but also IT. Perhaps the safety 1902 and is considered the ‘Father of Avi- tor's prescription. We still need to take section and the technology section could ation Safety.’ He started with the U.S. Air the medicine. So the second problem is come together to develop a solution for Mail Service, and at that time one in four how many recommendations out of the a simulator to help solve this problem of airmail pilots died from air accidents. He 32 percent of reports issued were imple- lack of field experience due to the scarci- led us to establish aviation safety. If we mented? The third problem is if we go ty of air accidents. look at the history of what he did in the through the 32 percent of the reports, we “I maintain that human factors are 1930s for aviation safety, it’s similar to would see disagreements that came out the center of everything in aviation what we do today with SMS. He started a during the investigation. Disagreements safety. Even if we end up with drone safety office and developed an education are not necessarily bad, but we have air transport, it will be humans man-

January-March 2019 ISASI Forum • 15 ufacturing the drones and humans flying the drones. Maybe pilots will PAST LEDERER AWARD WINNERS not be sitting in the aircraft but flying from some remote location. These 1977—Samuel M. Phillips new pilots may not be tracking one 1978—Allen R. McMahan aircraft—they may control 10. So a 1979—Gerard M. Bruggink human error in that context could be more catastrophic; we have to watch 1980—John Gilbert Boulding this closely. 1981—Dr. S. Harry Robertson “We also need to look at the multi- 1982—C.H. Prater Houge disciplinary approach to aviation safety. In recent years, we have seen 1983—C.O. Miller fewer major air accidents so what are 1984—George B. Parker air safety investigators going to do? 1985—Dr. John Kenyon Mason Other than working with operators 1986—Geoffrey C. Wilkinson and manufacturers to resolve or avoid events and incidents, air accident in- 1987—Dr. Carol A. Roberts vestigators can look at accidents that 1988—H. Vincent LaChapelle occur outside the aviation sector. I 1989—Aage A. Roed know we can learn from other transportation accident investigations and 1990—Olof Fritsch other industries. 1991—Eddie J. Trimble “This brings us to the 4 Cs that I 1992—Paul R. Powers would like to see implemented: coop- 1993—Capt. Victor Hewes eration, communication, conclusion, and change. 1994—UK Aircraft Accidents Investigation Branch “We need to develop better cooper- 1995—Dr. John K. Lauber ation, not just within an investigative 1996—Burt Chesterfield body but among investigative bodies, airlines, manufacturers, regulators, 1997—Gus Economy governments, and international or- 1998—A. Frank Taylor ganizations. 1999—Capt. James A. McIntyre “We need better communication. 2000—Nora C. Marshal Communication is like engine oil. If you run a combustion engine without 2001—John W. Purvis and the oil, it will fail—even if it's the best Transportation Safety Board of Canada engine in the world. 2002—Ronald L. Schleede “We need to come to some conclu- 2003—Caj Frostell sions—we cannot leave investigations open for years and years. We need 2004—Ron Chippindale to know what happened in a timely 2005—John D. Rawson manner. Even if we cannot come to a 2006—Richard H. Wood conclusion, we need to put the facts forward and declare that this is what 2007—Thomas McCarthy we see. 2008—C. Donald Bateman “We need to adapt to change and 2009—Capt. Richard B. Stone and the adopt a management of change pro- Australian Transport Safety Bureau cess. This is the only way to achieve 2010—Michael Poole continuous improvement. “Having said that, that's the benefit 2011—Paul-Louis Arslanian of my 45 years of aviation safety. I 2012—Curt L. Lewis don't know how many years I have left, 2013—Frank Del Gandio and Myron Papadakis but I will continue to work for aviation safety as long as I live.” Aziz conclud- 2014—David King ed, “I would like to thank everyone for 2015—Ladislav (Ladi) Mika being here at the seminar—the 2016—Eugene (Toby) Carroll sponsors and all the people and organizations that made this seminar 2017—Chan, Wing Keong possible in this part of the world.”

16 • January-March 2019 ISASI Forum Adapted with permission from the author’s technical paper titled EASA Involvement in Safety Investigations presented during ISASI 2018, Oct. 30–Nov. 1, 2018, in Dubai, United Arab Emirates. The theme for ISASI 2018 was “The Future of Aircraft Accident Investigation.” The full presentation can be found on the ISASI website at www.isasi.org in the Library tab under Technical Presentations.—Editor EASA INVOLVEMENT IN SAFETY INVESTIGATIONS

By Mario Colavita, Safety Investigation and Reporting Section Manager, European Aviation Safety Agency

Introduction of the European Parliament and of the In its multiple roles of regulator as well council of Oct. 20, 2010, on the investi- as certification and standardization gation and prevention of accidents and authority, the European Aviation Safety incidents in civil aviation. Agency (EASA) has always recognized Regulation (EU) No. 996/2010 im- the strategic safety value of accident plements international standards and investigations. For this reason, following recommended practices as described in the entry into force of Regulation No. Annex 13 of the Chicago Convention on 996/2010 of the European Parliament International Civil Aviation. It sets down and of the council on the investigation an obligation for each member state of and prevention of accidents and inci- the EU to establish an independent and dents in civil aviation, EASA has been permanent national civil aviation safety continuously increasing its level of investigation authority that shall inves- engagement in accident investigations tigate accidents and serious incidents to to actively contribute to them and, at improve aviation safety and to prevent the same time, to have the opportunity future occurrences without apportioning to learn lessons from the field to convert blame or liability. Investigation reports Mario Colavita into timely safety actions. and the related safety recommendations This paper describes the internal shall be communicated to the concerned protocols EASA uses to comply with ac- aviation authorities for consideration cess to information and confidentiality and for appropriate action, as needed. requirements during a safety investiga- In particular, Regulation (EU) No. tion, as well as the resources specifically 996/2010 takes into account that EASA dedicated to support the investigation. carries out on behalf of member states Moreover, the paper presents the the functions and tasks of the state of range of activities that EASA has recently design, manufacture, and registry when undertaken to strengthen the links with related to design approval, as speci- safety investigation authorities (SIAs) fied in the Chicago Convention and its worldwide and to further increase the annexes. Therefore, it establishes EASA’s internal capabilities to provide effective right to participate in a safety investi- support to their independent invest- gation to contribute, within the scope igations. of its competence, to its efficiency and to ensure the safety of aircraft design without affecting the independent status Background of the investigation. At the European Union (EU) level, the Article 8 of the abovementioned reg- principles governing the investigation ulation is specifically dedicated to the of accidents and serious incidents are participation of EASA (and national civil defined in Regulation (EU) No. 996/2010 aviation authorities of member states) in January-March 2019 ISASI Forum • 17 safety investigations. In accordance with out in 28 member states, EASA identi- currently made up of seven members, that, SIAs shall invite EASA to appoint a fied the need to create an internal team acts as a bridge between the agency and representative to participate devoted to safety investigations and the SIAs of member states and facilitates (a) as an adviser to the investiga- management of related safety recom- an intense exchange of information and tor-in-charge in any safety investigation mendations. This team currently is part data between the entities. The team con- under Article 5 (1) and (2) conducted in of the Safety Investigation and Reporting sists of a group of experts that is made the territory of a member state or in the Section in conjunction with the Internal up of a wide range of nationalities and location referred to in Article 5 (2) under Occurrence Reporting Section team backgrounds. The cross-domain nature the control and at the discretion of the that represents the single entry point for of safety investigations makes the safety investigator-in-charge; all safety-related occurrences that are investigation team a core unit of EASA, a (b) as an adviser appointed under reported to EASA. team that is highly interconnected with this regulation to assist accredited rep- The section is part of the Safety Intel- all other departments and is in direct resentative(s) of member states in any ligence and Performance Department, contact with senior management. safety investigation conducted in which is part of the Strategy and Safety Due to the confidential and sensitive a third country to which a safety inves- Management Directorate that is respon- nature of the data received, Article 15 tigation authority is invited to designate sible for developing EASA strategy, key of Regulation (EU) No. 996/2010 also an accredited representative in accord- programs, and plans, as well as interna- establishes EASA’s obligation to pro- ance with international standards and tional cooperation, technical training, tect information in accordance with recommended practices for aircraft and research and safety promotion the provisions established for SIAs. To accident and incident investigation, activities. comply with this requirement, EASA has under the supervision of the accredited EASA’s safety investigation team, put in place very strong internal proto- representative. The same article details the activities Table 1. Amount of Investigation Information Processed at EASA in which EASA is entitled to participate. Among them are to YEAR 2017 YEAR 2018 • receive copies of all pertinent doc- (until end of July) uments and obtain relevant factual information, Notifications 825 578 • participate in the readouts of recorded media, except cockpit voice or Interim Reports 33 22 image recorders, and Draft Reports 170 92 • participate in offsite investigative activities such as component ex- Final Reports 579 302 aminations, tests and simulations, technical briefings, and investigation progress meetings. Furthermore, Article 9 establishes an obligation to the SIAs of member states to notify EASA, without delay, “of all accidents and serious incidents of which it has been notified.”

EASA engagement The multiple roles of EASA in regulation, certification, and standardization show the strategic nature of the engagement in safety investigation in order to react in a timely fashion to identify a safety issue to be addressed, but also to be able to support the investigation by providing information and advice as necessary. In 2009, to cope with the expected high volume of investigations carried Figure 1. Number of safety recommendations treated at EASA.

18 • January-March 2019 ISASI Forum possible to understand • more than 82 percent of the safety a link with similar cases recommendations received were already handled in the “agreed” or “partially agreed” in 2017 past, this procedure can (see Figure 2). be sidestepped and a • 85 percent of the assessments re- more focused member ceived to the closing replies provided with the most appro- in 2017 by EASA were “adequate” (68 priate background and percent) or “partially adequate” (18 expertise is designated. percent) (see Figure 3). The amount of data managed by EASA is The excellent level of maturity reached shown in Table 1, which in the internal processes established in summarizes the most this area was certified during the last Figure 2. Safety recommendation replies sent in 2017: recent figures in terms international Civil Aviation Organization EASA assessment. of notifications of newly (ICAO) audit (November 2017), when the opened investigations applicable protocol questions regarding and interim, draft, and accident investigation were assessed at final reports received. 100 percent of effective implementation. The significant effort EASA had previously supported, behind treating this specifically in areas of accident investi- massive amount of data gation, the Asia Pacific Combined Action is complemented by the Team (CAT) program undertaken by the additional processing ICAO Regional Office of Bangkok aimed of safety recommenda- at conducting an assessment and gap tions (SRs) addressed analysis of Universal Safety Oversight to EASA, which re- Audit Program protocol questions in ar- mains the main single eas of low effective implementation and EU addressee of safety to assist member states in attaining the recommendations. The most readily achievable improvement. number of safety recom- Between 2016 and 2017, EASA safety Figure 3. Response assessment received on final replies mendations is summa- investigation team members acted as provided in 2017. rized in Figure 1. experts during the CAT program ICAO In accordance missions to assist the SIAs of Bangla- desh, Cambodia, Indonesia, and the cols so that all information always goes through the with Regulation No. 996/2010, Article 18, Philippines. safety investigation team. Access to this information is In addition, members of the safety in- always strictly limited to the experts who need to use it “Follow-up to safety recommendations and vestigation team have also been engaged and who are informed about the prohibition to further in the European Common Aviation Area disseminate it. safety recommendations database,” this agreement to assess the current status When the notification of a newly opened investiga- aspect is further accom- of the expected transposal and imple- tion is received at the functional mailbox, investiga- plished by an additional mentation of EU regulations pertaining [email protected], EASA’s safety investigation team internal process to as- to accident investigation into Serbian acknowledges its receipt. With the same response sess safety recommen- national legislation. EASA is expected e-mail, EASA designates a technical adviser as a point dations and the related to provide a similar commitment to the of contact who can assist the investigator-in-charge (or replies provided. other western Balkan states involved in the accredited representative depending on the circum- The data reported in the agreement. stances) during the investigation. the Annual Safety Rec- EASA’s technical adviser is always a member of ommendation Review Not only desk work the safety investigation team. The standard process 2017 clearly references Since its establishment, EASA has been requires that the technical adviser be the officer of the this aspect and reflects steadily increasing its direct participa- team who is “on duty” on a weekly basis and in charge the high degree of tion in safety investigation, always fully of the correspondence received in the functional mail- acceptance of safety respecting the independence of SIAs. box. However, in those cases in which a specific level recommendations that Table 2, page 21, shows the number of of expertise is more easily predictable, or where it is EASA receives: requests for assistance/support EASA

January-March 2019 ISASI Forum • 19 has recently received requiring the iden- At EASA, these differences are also activities like collaborative groups or an tification and involvement of its most considered depending on the areas of SIB rather than a rulemaking process. competent experts. competences that are involved in the When rulemaking is considered nec- In a select number of investigations, safety issue identified by the investiga- essary, it implies a different magnitude there is a need for more in-depth partic- tion. As a matter of fact, in many cases of time to reach a conclusion that is ipation. This is the case when joint de- the information shared by SIAs during barely compatible with the completion briefing meetings are organized during an investigation has identified an unsafe of a safety action in the timeframe of an the investigation on aspects that could condition that would warrant an airwor- investigation. have substantial relevance for EASA, thiness directives (AD) action under EU Similar consideration applies to such as airworthiness or the operation of Regulation No. 748/2012, Part 21.A.3B. research activities that may also be an aircraft. This has then been timely transposed prompted by the safety investigation. As an example, the following is a into mandatory actions implemented by This is a tool in which EASA is currently list of the investigations of events that EASA to ensure, as temporary or conclu- planning to invest more, but from the occurred in 2017 that required the direct sive measures, the continuing airworthi- planning of research to its conclusion participation of EASA safety investiga- ness of the fleet. and possible implementation of results, tion team members: This was also the case of some of the the timeframe becomes often imprac- • ACC L410, RA-67047—in-flight investigations listed previously (L410, tical to be presented as safety actions activation of beta reverse mode that 332L, and A380). already implemented at the release of occurred in Russia on Nov. 15, 2017. Furthermore, there are a number of the final report. • ACC AS332L, JA9672—in-flight sep- circumstances in which EASA is also aration of tail rotor gearbox and tail intervening by issuing a safety informa- EASA level of integration with SIAs tion bulletin (SIB), a different tool that is rotor hub that occurred in Japan on Since 2005, EASA has been organizing particularly useful to tackle operational Nov. 11, 2017. and hosting an annual coordination concerns. An example is the issuance • ACC A380, F-HPJE—engine No. 4 fan meeting with SIAs of member states. of the SIB drawing attention to the risk and inlet separation that occurred The event has now reached a high level of rotating too slowly during departure when overflying Greenland on Sept. of maturity, and since 2016 it has been from runways where performance-limit- 30, 2017. extended to the current format of one ing factors are present. and a half days. The meeting is intended • SI A340-300, F-GLZU—slow rotation SIBs have also been introduced during at takeoff that occurred in Bogota, to cover the status of the key enablers for the investigation as additional opera- Colombia, on Mar. 11, 2017. the future development of safety investi- tional barriers to reinforce safety nets • CL-604, D-AMSC—wake turbulence gation in Europe. It offers a great oppor- when the safety concern is not con- tunity to encourage participants to share encounter that occurred when sidered to be an unsafe condition that overflying the Arabian Sea on Jan. 7, information on a significant number of would warrant an AD action under EU 2017. relevant topics that have been studied Regulation No. 748/2012, Part 21.A.3B. or investigated during the previous year. This was the case regarding the SIB on The meeting is also intended to promote Involvement in investigations severe propeller/engine vibration events enhancements in data exchange and promoting safety actions investigated by Sweden and France on analysis between SIAs and EASA aimed The current trend, for many SIAs in the ATR aircraft during descent when flying at identifying and assessing systemic world, is to promote safety actions dur- close to maximum operating speed with risks. ing the investigation to be acknowledged power in flight idle. EASA published SIB Since 2018, EASA has further strength- in the final report instead of issuing a 2015-03 (superseded on Jan. 19, 2016, by ened the links with SIAs in Europe and safety recommendation in the end. SIB 2015-03R1) to improve crew aware- worldwide, promoting a series of bilat- From EASA’s perspective, this is seen ness about this type of vibration event eral meetings where, face-to-face and in principle as a very welcome step for- and to allow a better and prompt identi- through tailored agendas, there is the ward. However, it should be recognized fication of the issue and the application opportunity to discuss topics of common that the implications of this approach of conservative measures. interest. are very different when considering In general terms, there is a shift cur- This project has been started with different addressees (e.g., an operator or rently ongoing at EASA to address more the UK AAIB and the Dutch DSB. More a regulator). safety issues through safety promotion meetings are planned with the French

20 • January-March 2019 ISASI Forum BEA, the Greek HAAIB, the Portuguese GPIAA, and the Spanish CIAIAC. This project will continue, and YEAR 2017 YEAR 2018 preliminary contacts have already been made with (until end of July) the Finnish SIA and the Italian ANSV. Number of 82 53 Outside of EU borders, an exchange program has requests been established with the U.S. National Transporta- tion Safety Board (NTSB) that will lead to having a Table 2. Requests for Assistance/Support Received from State Investiga- member of EASA’s safety investigation team staying at tion Authorities During an Investigation the NTSB for four weeks to cooperate on investigation matters. opportunity to see on site how an SIA with limited resource would re- EASA has also been granted access, as an observer, act to a major occurrence is undoubtedly very advantageous in terms to the meetings of the European Network of the Civil of an SIA preparing for any future event. It is also important to fully Aviation Safety Investigation Authorities (ENCASIA), appreciate the relevance of ENCASIA’s effort to promote structured whose activities are aimed at further improving support provided by more experienced investigation authorities. the quality of investigations conducted by SIAs and strengthening their independence. This is a great Safety investigation in the framework of EASA’s SRM process opportunity for EASA to strengthen the cooperation EASA’s safety risk management (SRM) process is based on the estab- with SIAs of member states, since it gives the agency lishment of safety risk portfolios (SRPs) and provides for different op- a chance to actively contribute to some of the work- erational domains data driven input to the decision‑making process ing groups that are generated by this network. In that supports the European Plan for Aviation Safety. particular, the work done by Working Group 6 was The systemic list of “safety issues” collected in the SRPs specifically established to address the subject of safety recom- identified per each aviation domain are the areas of concern covering mendations to work toward consistency and common one or more identified safety deficiencies that may lead to an acci- procedures among members states in order to dent. • provide assistance to ENCASIA to achieve an effective management of safety recommendations EASA’s involvement in safety investigations is a powerful enabler to information system database and to ensure com- timely update the information available in the occurrence data, one pliance with the current EU regulation frame- of the main pillars of the SRM, with the objectives to allow work, • an adequate internal and external coordination on the identification and assessment of safety issues, as well as the programming • provide guidance on best practices for developing of the safety actions, and and processing safety recommendations, and • the prioritization of safety actions that are most efficient in -re • provide the views and opinions of ENCASIA ducing risk levels. on developments in occurrence reporting that directly relate to accident and serious incident investigation under EU Regulation No. 996/2010. Conclusion EASA was recently invited by some of the states EASA’s involvement in safety investigations has been growing over hosting the activity to take part in exercises organized the years in full respect of international standards and the complete in the framework of the ENCASIA Mutual Support independence of SIAs. System (EMSS) Project. This activity is intended to Regulation (EU) No. 996/2010 is key in clearly identifying EASA’s help EU states that are less capable and/or experi- role and responsibilities in the framework of investigations. Since its enced in conducting a major or complex civil aircraft introduction, significant improvements have been achieved, mostly safety investigation, identifying their capability gaps driven by the mutual trust that has been built between EASA and in order to develop contingency plans and establish SIAs of member states. prior arrangements with other states. The objective is The strategic importance of a fair and timely sharing of informa- to enhance the competence and confidence of the SIA tion between EASA and SIAs fully justifies the investment in the in leading a major safety investigation and maintain- resources that the agency is currently devoting in this matter. ing public confidence in aviation. The plans and the actions currently in place are aimed at further In June 2018, EASA participated in EMSS exercises strengthening the cooperation with SIAs and enhancing EASA’s organized in Iceland and Slovenia. EASA considered ability to provide the assistance requested for successful the outcome of the exercise to be very positive. The investigations.

January-March 2019 ISASI Forum • 21 INVESTIGATING OUR FUTURE By Nat Nagy, Executive Director of Transport Safety, Australian Transport Safety Bureau

he transport sector is changing at a rapid rate. More passengers are flying today than ever before. And Twhen they board an aircraft, it is increasingly likely to be one designed with advanced automation, state-of-the-art technology, and digital connectivity. This kind of “disruptive technology” challenges not only the aviation industry, but safety investigators in all modes of transport. There are complex and critical questions in relation to how safety investigation agencies are anticipating and preparing Figure for these challenges. How do we antici- 1: AO- 2010- pate the types of hazards and risks that 089 oil are likely to be contributing factors to a feed serious incident or accident in the near pipe. future? We need to better utilize data to become more predictive. We also need to understand what an investigation organ- AO, transformed aviation accident inves- of Transport in support of the missing ization will look like in the future. What tigations when it was first introduced in Malaysia Airlines Flight MH370, we rec- are the skill sets we should be recruiting the 1950s. And over the decades since, its ommended that states make certain that as investigators? Should we continue to design has evolved to be more durable sufficient mechanisms are in place to en- recruit pilots as investigators or should and to collect more data over longer peri- sure a rapid detection of, and appropriate we be looking wider at systems engineers ods. Flight data recorders today have four response to, the loss of aircraft position or or data coders? times the capacity of the original magnet- contact throughout all areas of operation. In this paper, the Australian Transport ic tape flight recorders; they can survive The ATSB also recommended that aircraft Safety Bureau (ATSB) outlines the work high-intensity flame for more than 30 operators, aircraft manufacturers, and it is doing to be future ready. The ATSB minutes and can operate even after water aircraft equipment manufacturers inves- recognizes that accident investigation immersion for 30 days at pressures equiv- tigate ways to provide high-rate and/or methodology as applied by today’s inves- alent to a depth of 20,000 feet. These and automatically triggered global position tigators will not necessarily meet states’ other changes are significant, and they tracking in existing and future fleets. expectations in five, 10, and 20 years. help us do our work to improve transport States and industry are taking action to When examining the aviation operating safety and ultimately save lives. respond to these recommendations. environment, the ATSB considers the Many of the safety changes and im- Change is the only constant in the avi- kind of expertise we will need, the type provements are a testament to the work ation industry and not new to this group and amount of data we will need to store of dedicated accident investigators such or to any aviation investigation agency. and analyze to become more predictive, as those in ISASI. The ATSB’s investiga- It is central to what we do. But we can ill and how we will communicate critical tion into a 2010 incident—an in-flight afford to be complacent about the future. safety issues to the industry, regulators, uncontained engine failure on an Airbus As leaders in aviation safety, we must and the public. The ATSB will evolve, as A380-824—found that a number of oil predict the challenges ahead to ensure we all accident investigation agencies must, feed stub pipes were manufactured with remain relevant and continue to improve to continue to be a relevant and integral thin wall sections that did not conform safety. part of the safety system, identifying the to the design specifications (see Figure The changes of the past, while sig- safety issues of tomorrow. 1). The investigation led to a number of nificant, have largely been gradual and Since the inception of manned flight, relatively small but significant changes: iterative. What we are seeing now, across aviation has been a dynamic mode of identification and replacement or man- many sectors, is a shift toward more sud- transport—continually evolving to be- agement of nonconforming oil feed stub den, disruptive change. “Disruptive inno- come safer, to carry a greater number of pipes, an engine control software update, vation” is the buzzword of our generation, passengers and heavier tonnage of cargo, and changes to the engine manufacturer’s and for good reason. Innovations such as and to become environmentally cleaner quality management system. the “sharing economy” (think Uber and and more efficient. For example, the flight More recently, in the course of the AIB’s Airbnb) are disruptive in that they are data recorder, invented by David Warren assistance to the Malaysian Ministry transforming the way people utilize re- 22 • January-March 2019 ISASI Forum Adapted with permission from the author's technical paper titled Investigating Our Future presented during ISASI 2018, Oct. 30–Nov. 1, 2018, in Dubai, United Arab Emirates. The theme for ISASI 2018 was “The Future of Aircraft Accident Investigation.” The full presentation can be found on the ISASI website at www.isasi.org in the Library tab under Technical Presentations.—Editor Nat Nagy

sources. This is not limited to holiday and supporting flight automation and a signif- due to the extent and base of the cloud, personal travel. There are a number of icant increase in workload while attempt- along with rising terrain in front of the share economy businesses in the aviation ing to conduct RNAV (GNSS) approaches aircraft, provided the pilot with insuffi- sector (or seeking to enter it), including into the airport. This increased workload cient time to diagnose, react, and recover Uber Elevate, Airpooler, and Uberjets. affected both the pilot’s ability to follow before the ground impact. These companies are innovating quickly established tracks such as the published There was no advice, limitation, or and are fundamentally changing the way approach and missed approach and his warning in the aircraft pilot operating the aviation sector operates. Traditional ability to communicate his position accu- handbook or avionics manual to indicate aviation companies and regulators are rately to other aircraft and the air traffic that if a force is applied to the control finding it challenging to keep up with controller. column while the autopilot is engaged these changes while potential customers In the second incident, a Cessna 172 the aircraft’s autopilot system will trim are changing their activities to adjust. collided with terrain resulting in fatal against the control column force and These and other disruptive innovations injuries to the pilot (see Figure 3, page 24). possibly lead to a significant out-of-trim will influence the world and the future of Our investigation found that the aircraft situation. Training requirements for aviation safety. impacted terrain in a level and slight right autopilot systems was rudimentary at the We need to prepare for increasingly wing-low attitude. This indicated that the recreational pilot license (RPL) level due unfamiliar environments with disruptive pilot likely stopped the aircraft’s descent to stipulated operational limitations for innovation—a rapidly changing transport and started to initiate a maneuver to its use. At the time of the accident, there environment. The ATSB is planning for avoid the terrain. It is likely that the pilot was no regulatory requirement for pilots the future by preparing a vision for 2025. manually manipulated the controls while to demonstrate autopilot competency at In this paper, I will provide examples of the autopilot was engaged in a vertical the RPL level. the key changes and trends we see emerg- mode. As a consequence, the autopilot re- Both accidents demonstrate that pilots ing that demonstrate why we expect the trimmed the aircraft against pilot inputs, need to have a thorough understanding future to rapidly change. I will also pose inducing a nose-down mistrim situation of all systems on board their aircraft and some challenging questions we should that led to a rapid descent. The aircraft’s have the skill to provide redundancy all be asking ourselves and outline what low operating height above the ground, when those systems fail or their perfor- the ATSB is doing to try to answer those questions.

The future of aviation Automation Automation is not new to the aviation sector. Autopilots have been used for decades, and even technologies such as ADS-C and terrestrial ADS-B have now been in use for some time across the globe. However, automation continues to advance and is no longer confined to the biggest and latest state-of-the-art aircraft, airports, and other aviation systems. We are seeing the effects of increased automation throughout the aviation sector now. In 2018, the ATSB released two investigation reports identifying pilot interaction with automated technology as a contributing factor to the accident. In the first incident, two Beech Aircraft Corp B200s were involved in a near collision (see Figure 2). Difficulties in oper- Figure 2: AO- ating the GPS/autopilot resulted in the 2015-108 radar pilot of one of the aircraft experiencing data showing the an unexpected reduction in the level of near collision.

January-March 2019 ISASI Forum • 23 functionality and performance requirements needed to meet all operational scenarios are incorporated within the design. It is also important that effective check and test processes are developed to fully validate system functionality. This is an important message for all transport modes, including aviation, as systems become more technically complex. Associated with the emergence of complex systems is the creation of “big data.” Ninety percent of digital data was created over the two years 2014 and 2015, Figure 3: AO- and the rate of data creation is increasing. 2015-105 acci- Transport systems, including aviation, are dent site. generating high volumes of data relating to routes, fuel efficiency, customer inter- actions, and maintenance. By collecting accurate, rapid, and comprehensive information, the aviation sector can improve productivity and efficiency. Remotely piloted technology Another emerging technology is remotely piloted aircraft systems (RPAS). The ATSB is closely monitoring the growth in this sector as it presents an emerging and insufficiently understood transport safety risk. Data about the number of RPAS (see Figure 4: Ballarat Figure 5) operating in Australia is limited. Railway Station. Australia’s civil aviation regulator certifies RPAS operators, but not all RPAS need to be certified. To estimate the total number of RPAS, we combine the regulator’s data Figure 5: An with Google trends shopping data. We use example of an this estimate to help predict occurrences. RPAS, the Pulse Data about occurrences such as colli- Aerospace sions and near encounters is somewhat Vapor 55. better. The ATSB receives occurrence reports from a wide range of aviation stake- mance is degraded. they for manufacturing, maintenance holders. At the time of writing this paper, Aircraft manufacturer plans and indus- scheduling, navigation, or all manner of the ATSB had received many reports try demand suggest that automation is other things, are increasingly relying on about RPAS occurrences but no reports likely to continue to advance throughout complex digital codes and algorithms. of collisions between RPAS and manned the aviation sector. This increases the Other transport modes are experiencing aircraft in Australia. Over half of all RPAS likelihood of systemic factors arising this same trend, and as a multimodal occurrences from January 2012 to June related to the design and operation of investigation agency, the ATSB is able to 2017 involved near encounters with automated systems. The challenge for share safety lessons and experiences from manned aircraft. The next most common investigators will be ensuring we can and these other sectors. type of occurrence involved collisions do identify those factors. We will need the In a recent rail investigation (see Figure with terrain, almost half of which resulted appropriate tools and expertise. As the 4), the ATSB determined that the comput- from a loss of control of the RPAS. level of automation increases, our inves- er system controlling movements of rail A key challenge for investigation tigation of human factors may shift from tracks was not operating as expected due agencies regarding RPAS is collecting and the capability of the pilot to the person to design errors in the system’s coding. analyzing data that will help us predict who coded the system that operates the Track maintenance workers were put future occurrences. As data about RPAS aircraft. at risk because the safety control they is difficult to collect, this could be an expected to be in place was not actioned. opportunity for agencies to cooperate and Big data and complex systems We identified a safety message—it is crit- share data internationally to form a more Many systems in the aviation sector, be ical that system designers ensure that the complete picture.

24 • January-March 2019 ISASI Forum What next? ple in the transport industry about how and coroners. All of these stakeholders Now that we have given some thought to the ATSB can best add value and support have some interest in improving safety what our future looks like, we need to ask the work they already do. We are talking and work to identify issues and take ourselves some difficult questions such as to the minister about what he and the action. Many of them have investigation Australian government expect from our capabilities and can identify safety issues agency. By asking questions and listening, What will we in minor and routine occurrences. investigate? we have learned a great deal—and their If they do this work, there may be no How will we input has been integral to developing our need for the ATSB to be involved. Rep- investigate? vision. licating the work of these stakeholders Why will we choose Our vision is “to drive safety action in a to investigate some would be inefficient and unlikely to occurrences and not rapidly changing transport environment.” lead to further safety improvements. INVESTIGATIONS others? This acknowledges the fast pace of change Instead, we should use our position as and our important role in identifying What data do we the independent, no blame investigator need to do our job safety issues and influencing improve- well? to investigate and research those issues ments. As with all vision statements, it is How will we collect that others cannot or will not. We are in and manage data? an aspirational target, supported by goals a unique position to raise the standard of How will we use data and strategies. These goals and strategies to inform our other center on ensuring that the ATSB remains investigations, conduct detailed technical DATA work? relevant and uses resources in the best work, and advocate for serious systemic Who will be our audi- change. ence? way to achieve safety improvements. For example, the ATSB investigated a How will they want to One of our aspirational goals is to be engage? Australia’s national transport safety inves- collision with terrain involving a Robin- What information will tigator. As we are a multimodal investi- son R44 helicopter. We also conducted we want and need to COMMUNICATIONS share? gation agency, covering aviation, marine, statistical analysis of helicopter accidents How will we be fund- and rail, it could be argued that we have that occurred in Australia and the United ed? already achieved this goal. However, we States between 1993 and 2013 and iden- Who will we work with? need to strategically consider where we tified a significantly higher proportion What technology and can best add value to the transport sector. of postimpact fires involving R44s than resources will we need OUR RESOURCES to do our work? We currently focus on passenger trans- for other similar helicopter types. The port across these three modes, but our What expertise do we analysis also identified that despite the need? expertise could potentially also assist in introduction of requirements for newly How will we engage protecting economic interests by focusing certificated helicopters to have an im- people to conduct on freight movements and damage to work? proved crash-resistant fuel system (CRFS) public infrastructure. We could poten- What will our workforce some 20 years previously, several helicop- OUR PEOPLE look like? tially also lend our expertise to other ter types were still being manufactured transport modes such as heavy vehicles. without a CRFS and that many of the ex- For example, a recent accident north of isting civil helicopter fleet were similarly Sydney involved a truck and six cars and What is the ATSB doing? not fitted with a CRFS. The ATSB issued resulted in two fatalities and multiple The ATSB has embarked on a major injuries. a safety recommendation about the risks project to challenge ourselves to ensure This stretch of road has been the site of involved in not having a CRFS. As a result, that we are prepared for the future. We several serious accidents, and an investi- Australia’s civil aviation regulator, and have chosen to focus on the medium gation into the accident could potentially other international regulators, took ac- term and what our vision is for 2025. This identify some systemic contributing tion to ensure that owners and operators vision will be a declaration of our intend- factors. The investigation techniques and made these improvements. The ATSB’s ed purpose and aspirations. It will guide expertise are largely transferable and investigation and research led to safety our strategies over the coming years, help could lead to improvements in road safety improvements that otherwise would not us communicate with our stakeholders and a reduction in fatalities. While these have happened. This is the kind of work about our purpose and value, and allow options require extensive consideration we should prioritize into the future. us to check if we are on track for achiev- by the agency and the government, we ing what we intend. are committed to think more strategically An important part of this process about what our role as Australia’s nation- Conclusion has been entering into conversations al transport safety investigator does and Our collective future lies in a rapidly with a wide variety of stakeholders. should mean, especially in the context of changing transport environment, and the We are talking to our staff—experts in future change. ATSB will continue to drive safety action. their fields—about what they see as the Another goal for 2025 is to expose the We have a great deal of research and emerging opportunities and challenges. critical safety issues that others do not. strategic planning ahead to determine We are talking to our government col- There are many relevant stakeholders in what our future direction should be. But leagues—policy makers, regulators, and each of our modes, including industry the process so far has been fruitful, and others—about how to best work together operators, private operators, regulators, we are better placed to continue being an to improve safety. We are talking to peo- policy owners, research bodies, police, integral part of the safety system.

January-March 2019 ISASI Forum • 25 ISASI International Council Conducts Semiannual Meeting By J. Gary DiNunno, Editor, ISASI Forum he Society’s international coun- members and 118 corporate members. The tion for upcoming annual seminars. cilors, executive officers, and com- Membership Committee’s main concern, • Tom Curran, chair of the Host Com- mittee and working group chairs Schleede reported, is recruitment and mittee for ISASI 2018, outlined the sched- Tmet in Dubai, the United Arab Emir- retention of individual and corporate ule for the session that would begin with ates, on Oct. 28, 2018, just prior to ISASI members as dues payments are the pri- tutorials the following day. 2018 to review the state of the organization mary source of ISASI revenue. He stressed • Daan Zwart, ISASI 2019 Host Com- and conduct business. Following approval that this matter requires the attention of mittee chair, reported on the upcoming of the minutes for the previous Interna- all Society members. Annual dues notices seminar preparation in the Hague. tional Council meeting, President Frank are now sent to members in October of the The seminar is scheduled for Sept. 3-5, Del Gandio reported on the results of the year before their due date of January 31. 2019, and is being put together with the 2018 election of ISASI officers: President— Schleede expressed thanks to Reachout cooperation of VNV (Dutch ALPA), the Frank Del Gandio, Vice President—Ron Workshop participants Embry–Riddle Dutch Safety Board, and Delft University Schleede, Secretary—Chad Balentine, and Aeronautical University, the University of of Technology. The seminar venue will Treasurer—Bob MacIntosh. Also elected Southern California, and Southern Califor- be the World Forum. Plans currently were U.S. SASI President—Toby Carroll nia Safety Institute for their recruitment include that on Sunday, September 1, and International Councilor—Caj Frostell. efforts. the International Council will meet in Del Gandio noted that the Latin Amer- Gary DiNunno, the editor of ISASI the morning followed by a masterclass ican Society recently held a meeting to Forum, discussed the final 2018 issue of the on the reconstruction site of MH17 in get that society restarted but that he was magazine that was in production at the the afternoon as part of the ISASI 2019 unable to attend. Daniel Barafani provided time of the International Council meeting program. MH17 will be an additional the group with the presentation that Del and addressed progress on creating a dig- item to the main program open to a fixed Gandio had planned to provide. ital form of the publication for members number of attendees, and requirements An updated privacy statement is now wishing to receive an electronic copy rath- are still to be determined. On Monday, included on the ISASI website. With this er than a one printed. DiNunno, on behalf September 2, the tutorials and Welcome change, ISASI is meeting all the privacy of Executive Administrator Dick Stone, Reception will take place. On Tuesday requirements of California and the U.S., reported on the status of ISASI’s website through Thursday, the seminar will con- Canada, and Europe. Canada SASI Presi- and ongoing projects, including publicity vene at the World Forum. On Tuesday dent Barbara Dunn explained that other for ISASI’s annual seminars. evening, an offsite dinner will be held at ISASI websites also must comply with the the Louwman Museum. On Wednesday new privacy statement and cannot include ICM Business Matters personal information about members. evening, a “pub quiz” will be scheduled, International Council officials continued and on Thursday evening the Awards Del Gandio reported that he recently previous discussions on proposed changes appointed Bill Bramble of the U.S. National Banquet will take place at Kurhaus to the seminar manual. On paper selec- Scheveningen Beach. The Companion Transportation Safety Board as the Human tion, council officials suggested language Factors Working Group chair and men- Program will include a tour of old and that “Government agencies, aviation new Holland on Day 1, and windmills, tioned that the new president of the New manufacturers, and corporate members Zealand Society is Graham Streatfield. He water, and cheese on Day 2. On Friday, may possess special authority within their September 6, there will be an optional noted that Vice President Schleede has areas of interest and competency. Serious been acting as the Membership Commit- all-day visit to Amsterdam. Zwart added consideration should be given to authors that Delft University of Technology will tee chair and is looking for a volunteer of papers who can well represent the pro- to assist him as an understudy. Schleede pay the seminar registration fee for four fessional perspective of his/her collective Kapustin scholarship recipients. Zwart discussed some challenges with the ISASI organization.” Language also proposed membership form that require attention. said there are two hotel options: included: “Material that castigates individ- Marriott the Hague, which has a total of MacIntosh briefed council members uals, regulatory agencies, governmental on the financial report and health of the 300 available rooms, and the Novotel, policies, or individual airlines will gener- Society. He noted that ISASI is finan- which has a total of 200 available rooms ally not be published unless presented as cially sound and that expenditures for (as overflow). an ISASI position or comment.” On the 2018 were within budget projections. He • Dunn, Host Committee chair of ISASI matter of who can and should have access discussed the need for completing IRS 2020, said that the seminar will be held to the information presented in technical forms to maintain ISASI’s nonprofit status in August at the Sheraton Montreal. papers/presentations posted to the ISASI in the U.S. and observed that ISASI also Plans are proceeding, and the council website, the International Council sug- holds funds for AsiaSASI and the inactive has previously approved the submitted gested allowing anyone to access papers Northern California Regional Chapter. He budget proposal. went over the proposed 2019 budget. Upon on the website without a password being further review, the International Council required. These suggested seminar manual approved the proposed budget for 2019. additions will be voted on during the May Reports of National Societies, Regional In a written Membership Committee 2019 International Council meeting and Chapters, and Councilors report, Schleede said that since October will become effective for ISASI 2020. International Council 2017 applications have been approved for Councilor Frostell told meeting partic- 199 new individual members and 10 new ISASI Seminar Committee Reports ipants that he appreciated having ISASI corporate members. He added that as of Dunn, ISASI Seminar Committee chair, led 2018 in Dubai as that decision is good f Sept. 13, 2018, ISASI had 1,301 individual a discussion regarding plans and organiza- or ISASI’s international image.

26 • January-March 2019 ISASI Forum AsiaSASI briefing in 2019 in lieu of an ESASI seminar on June 27, 2018, at the Museum of Flight in Yasuhiro Yamada discussed AsiaSASI’s in preparation for ISASI 2019. Seattle, Washington, USA. Richard Ander- submitted report. In 2017 the AsiaSASI son, an accident investigator for Boeing, was Executive Committee was elected: Presi- Korean SASI the featured speaker. Anderson discussed dent—Japan Transport Safety Board, Vice Soon-Cheol Byeon reviewed a written the status of several Boeing investigations. President—Civil Aviation Department of report that was provided. He discussed the He is the Boeing focal point for investigating Hong Kong, and Secretary—Transport Reachout Workshop in Seoul, South Korea, the disappearance of MH370. The chapter Safety Investigation Bureau. The Execu- that occurred on Jan. 30–Feb. 1, 2018, at planned a fall 2018 visit to the Boeing Safety tive Committee’s term runs until Sept. 4, the Korea Aerospace University. Schleede Promotion Center at the manufacturer’s 2019. Hong Kong has recently formed an and Elaine Parker were the lecturers and widebody production facility in Everett, independent investigation authority, the discussed aircraft accident/incident inves- Washington, USA. Air Accident Investigation Authority. The tigations, along with emergency response Hong Kong Civil Aviation Department is no planning and risk management. Byeon Reports of Committees and Working longer responsible for Annex 13 investi- also provided a presentation on recorders, Groups gations. The Civil Aviation Department along with discussions on the UAV investi- Rudy Kapustin Scholarship Committee recently expressed a desire to step down gation manual and UAV security. Committee Chair Balentine reported that as vice president, and an election will be the Scholarship Committee received 11 Pakistan SASI scheduled to fill that position. (Editor's submissions for 2018 and selected four Naseem Ahmed discussed a written report note: The Hong Kong AAIA was subse- scholarship recipients: Katharina Ertman— that was provided. During the Pakistan quently elected.) The Executive Committee Delft University of Technology, Avery Katz— SASI annual meeting in April 2018, the was slated to meet Nov. 7, 2018. Addition- Embry–Riddle Aeronautical University, Ian society decided to sponsor one student and ally, the Transport Safety Investigation Low—University of New South Wales, and one full member to attend ISASI 2018. The Bureau planned to host a two-day AsiaSASI Nicolette Meyer—Embry–Riddle Aeronau- society planned a SASI Pakistan seminar at workshop on Nov. 8–9, 2018. tical University Worldwide. He noted that Lahore in December 2018. The Executive these four students would be in attendance Committee met in July 2018 to finalize de- Australia SASI (ASASI) at the seminar and provide a short pres- tails. A one-day seminar on personal safety A submitted written report indicated entation on their topic. They would also be was held in August 2018. Pakistan SASI also that the 2018 ANZSASI conference was the microphone runners for delegates who held a picnic at the Army Proof Range on very successful, providing two days of wish to comment or have questions from the Sonmiani Beach on August 14 to promote presentations that allowed the exchange seminar floor. of ideas and new concepts. A total of 92 the society among students. delegates and 18 partners from Australia, Reachout Committee New Zealand, the U.S., Singapore, and the U.S. SASI Schleede noted that the ISASI Reachout UK attended. Preliminary discussions are Carroll, U.S. SASI president, noted that the program has become nearly dormant, add- under way to select a location for ANZSASI national Society has 600 members and 11 ing that he had participated in a few recent 2020 in Australia. chapters. Two chapters need leadership. Reachout programs. Gandio suggested He also discussed the reports submitted the need to establish a team to assist with New Zealand SASI (NZSASI) by both the Dallas-Ft. Worth and Pacific Reachout activities. In a submitted written report, Alister Northwest Chapters. U.S. SASI partnered Buckingham, the New Zealand councilor, with the Southeast Regional Chapter for a Cabin Safety Working Group said that since the spring International seminar in Savannah, Georgia, USA. Carroll Working Group Chair Dunn reported that Council meeting, members and officers and Del Gandio designated Anthony Brick- the group continues to engage with the of NZSASI attended the annual combined house as the U.S. SASI vice president. International Civil Aviation Organization on ASASI/NZSASI regional seminar held in cabin safety. At the working group meeting, Melbourne, Australia, over the weekend of Mid-Atlantic Regional Chapter (MARC) there was a briefing from Emirates on cabin June 1–3. During that meeting, plans for Schleede briefed the International Council safety issues during a recent accident. the 2019 regional seminar were announced. on the MARC leadership changes. The 2019 The 2019 meeting will be held in Welling- MARC dinner would be on May 2 in Hern- Corporate Affairs Working Group ton, New Zealand, from June 7–9. The Civil don, Virginia, USA, and the next Interna- Working Group Chair Erin Carroll reported Aviation Authority of New Zealand will tional Council meeting will be held May 3. that 25 corporate members were past due host a related meeting of the Asia-Pacific for renewal as of August 2018. Of those past Cabin Safety Working Group on Friday. Dallas-Ft. Worth Regional Chapter (DFWRC) due, seven have indicated they wanted to Both groups will hold their formal business DFWRC President Erin Carroll said the retain membership. meetings immediately following the semi- chapter had a meeting on Sept. 6, 2018. Vir- nar on Saturday. gin Galactic Director of Safety Tim Logan ISASI Coordinator of Student Outreach & was the dinner speaker. Logan provided an Mentoring Report European SASI (ESASI) overview of commercial space investiga- Anthony Brickhouse noted that college and Robert Carter noted that members met in tions. universities are just getting started for the Latvia for the European regional meeting semester and are reengaging. He asked for on May 23–24. There were 120 attendees, Pacific Northwest Regional Chapter (PNRC) mentors and potential students to reach out and a military tutorial preceding the event. Acting PNRC President John Purvis said to him, noting that he would be pairing up He noted that Rolls-Royce would provide a the group held a meeting with 21 attendees students and mentors in the near future.

January-March 2019 ISASI Forum • 27 NEWS ROUNDUP

Plans for 2019 ANZSASI Seminar Set; certified design. Officers Shift Positions and Locations • The contribution of accident and incident investigation to risk management at the level of the manufacturer and regu- New Zealand Councilor Alister Buckingham reported that the lator. main event on the radar is the joint seminar of the Australian • The relationship between the continuing airworthiness and New Zealand Societies to be held in Wellington, New Zea- processes dealing with in-service incidents and an Annex 13 land, on the weekend of June 7–9. The invitation, call for papers, investigation. Are they complementary? and seminar registration form are currently posted on the ISASI • The added value of an Annex 13 investigation led by an inde- website. During the seminar weekend, ASASI will hold its annual pendent safety investigation authority and the challenges of general meeting and NZSASI its biennial general meeting. investigating design aspects. Late 2018 saw some changes in NZSASI. The secretary/treasur- • Is a new approach required to improve the timely identifi- er stood down because of other commitments, and that position cation of design-related safety issues and to enable practical was taken over by the previous incumbent, Russell Kennedy. solutions to be developed? Buckingham filled the VP position previously occupied by Russell. • How can investigators gain the knowledge, skills, and experi- President Graham Streatfield recently took a new position in ence necessary to investigate design aspects effectively? Washington, D.C., as the New Zealand air attaché and will be par- ticipating in society affairs remotely for the time being. Similarly, Session 2: How effective are safety recommendations and safety the seminar lead, Laurie Earl, has taken an academic post in the actions related to aircraft design? UK and will also be operating remotely. She’ll continue to be a Moderator: Graham Braithwaite, Cranfield University joint recipient of seminar papers per the website notice. Topics to be covered In the lead-up to the June seminar, NZSASI will be holding its • The safety recommendation process across the European biennial election of officers, with the successful candidates being Union. confirmed at the biennial general meeting. • What constitutes an effective safety recommendation on design aspects? NTSB Vice Chairman to Speak at MARC Dinner • The difference in approach for technical, procedural, and human performance recommendations. Mid-Atlantic Regional Chapter President Frank Hilldrup • The role of safety actions versus safety recommendations. recently announced and posted on the ISASI website plans for • Factors that influence the decision to take a design-related the annual dinner meeting to be held in Herndon, Virginia, safety action or issue a safety recommendation. USA, at the Crowne Plaza Dulles Airport Hotel on May 2 from 6:00–9:30 pm. • Factors that influence the timeliness of change. The main speaker for the event will be NTSB Vice Chairman Bruce Landsberg. Session 3: How can we further improve the relationship among Hilldrup asked that people wishing to attend the dinner make investigators from safety investigation authorities, manufacturers, reservations early as space is limited and a final dinner count regulators, and operators? with the hotel needs to be confirmed by Thursday, April 18. Moderator: Nunu Aghdassi, NetJets Participants who wish to stay at the hotel should immediately Topics to be covered • The routine collaborative working environment versus an check with ISASI Office Manager Ann Schull to reserve a independent accident investigation. blocked room at a special ISASI rate. The block will expire on April 1. Additional details and driving directions can be found • Safety data is routinely collected by the manufacturer, oper- on the ISASI website under the Events tab. ator, and regulator. How to gain access to this data without jeopardizing day-to-day safety protocols while ensuring an effective investigation. ESASI Plans Workshop for May • The different roles of the European Aviation Safety Agency in a safety investigation in relation to its various functions (certi- European Society President Olivier Ferrante reported there will be fication, rulemaking, safety promotion, standardization). a workshop at the Rolls-Royce Learning and Development Center • Small organizations can feel left out of the investigation pro- in Derby, UK, on May 22–23. The workshop theme is “Safety In- cess and may require greater support. vestigation throughout the Aircraft Life Cycle—Design for Safety.” The proposed program includes the following: • Increasing aircraft complexity to the extent that, at times, only the manufacturer has the tools and expertise needed to Session 1: How can the investigation of design aspects be enhanced allow the determination of causal factors. to improve safety throughout the lifecycle of an aircraft? • International perspective (U.S. National Transportation Safety Moderator: Crispin Orr, AAIB Board). Topics to be covered • The design process for a modern aircraft and the things that must be considered before making changes to a For more information on this seminar, go to www.esasi.eu.

28 • January-March 2019 ISASI Forum NEWS ROUNDUP

ISASI Member Becomes GM of Safety ISASI 2018 Technical Program and Quality Assurance at PIA (Continued from page 7)

ISASI President Frank Del Gandio and ISASI International 1515 “Use of sUAS in Developing Photogrammetric Model for Wind Simula- Councilor Caj Frostell recently congratulated ISASI member tion”—Mike Bauer, NTSB and B-777 Capt. Moshin A. Khan on his appointment as general manager of safety and quality assurance at Pakistan Internation- Wednesday, Oct. 31, 2018 Morning Session Moderator—Abdulelah O. Felimban, KSR AIB al Airlines (PAI). Frostell said, “With your extensive experience 0900 in aviation safety and your long-standing cooperation and inter- “EC225 LP Accident near Turøy, Norway”—Kåre Halvorsen and Tor est with ISASI and ISASI activities, you are an excellent choice Nørstegård, Norway AAIB 0930–1000 for the high-level safety job.” “EASA Involvement in Investigations”—Mario Colavita, EASA “Very good news,” Del Gandio added. “I join Caj in sending you 1030 accolades. I wish you every success in your new position .Warm “The Growing Level of Aircraft Systems Complexity and Software Inves- tigation”—Paulo Soares Oliveira Filho, Embraer regards to you and your wife.” 1100 The ISASI officials added, “The Society is looking forward to “Investigating How Regulators and Industry Endeavour to Address the continued close cooperation between our corporate member PIA Risks of Erroneous Data Entries”—Florent Duru and David Nouvel, BEA and ISASI and hopes to see you and your team at the ISASI 1130–1200 ISASI Business Meeting annual seminar in 2019 in the Hague, the Netherlands, from 1330 September 1–6. Kind regards.” Afternoon Session Moderator—Ibrahim Al Koshy, Saudia Airlines “The National Transportation Safety Board’s Family Assistance Pro- gram: Current Status and Challenges”—Elias J. Kontanis, NTSB 1400 “Implementing GCAA (Part III CAR-FAP) Aviation Disaster Family Assistance Plan”—Gill Sparrow, Emirates 1430–1440 Kapustin Scholar Presentation: “Skydiving Operations and Air Safety Investigation: How an Extreme Sport Highlights Broader Issues for Air Safety Investigators”—Avery Katz, Embry–Riddle Aeronautical Universi- ty 1510 “Investigating Our Future”—Nat Nagy, Australian Transport Safety Bureau 1540 “5mm Crack Leads to Engine Fire”—David Lim, TSIB Singapore Thursday, Nov. 1, 2018 0830 Morning Session Moderator—Mark Burtonwood, Emirates Keynote Address—Graham Braithwaite, Cranfield University 0900 “Shoreham Airshow—A Simple Accident?”—Alan Thorne, UK AAIB 0930-1000 Capt. Moshin A. Khan (Pakistan International Airlines) and his wife Soofia “Just Culture—Weak Link or Vital SMS Component”—Andreas Mateou, at ISASI’s 2018 seminar. Cobalt, and Sofia Mateou, ALS Aviation 1030 “Aircraft Tire Hydroplaning and How to Analyze It in Runway Excursion Events”—Gerard Van Es, Netherlands Aerospace Centre-NLR ISASI to Attend ICAO Meeting in Montreal 1100 “Investigation of Decision-Making during a Rejected Landing Occur- ISASI Vice President Ron Schleede and Treasurer Bob MacIntosh rence”—Wen Chin Li and Morris Yang, ASC Taiwan will represent ISASI at the 5th annual meeting of the Interna- 1130–1200 Kapustin Scholar Presentation: Big Data—Thinking Big for Aircraft tional Civil Aviation Organization (ICAO) Accident Investigation Accident Prevention”—Ian Low, University of New South Wales Panel (AIGP5) in Montreal, Que, Canada, from April 30 to May 2. 1330 About 40 specialists from some 20 countries and international Afternoon Session Moderator—Khalid Al Raisi, GCAA “Improving Safety with Few Accidents Occurring”—Bertrand de Cour- observer organizations will continue their work to update and ville, Air France, Ret. improve ICAO standards and recommended practices and guid- 1400 ance materials regarding accident/incident investigations and “Reducing Fleet Disruption through Human Factors Data Assign- ments”—David Chapel and Eston Betts, GE prevention. 1430–1440 ISASI’s role as an approved international observer organiza- Kapustin Scholar Presentation—“Electric Air Taxis and the Adaptation tion at ICAO has assisted the AIGP to make significant upgrades of the Air Safety Investigator”—Nicolette Meyer, Embry–Riddle Aero- nautical University to ICAO materials over the past six years. One of ISASI’s impor- 1510 tant contributions was the development of ICAO guidance Innovative Technologies Deployed in Recent Investigations”—Sundeep material on investigation of unmanned aircraft systems that Gupta and Albert Urdiroz, Airbus, and Anders Kristensen, AIB Denmark began as an ISASI manual. Other improvements have stemmed 1540 ISASI 2019—The Hague, the Netherlands from input by ISASI members at the meetings. Closing Remarks—Frank Del Gandio January-March 2019 ISASI Forum • 29 ISASI HOLDS 2018 SEMINAR IN DUBAI, UAE ISASI INFORMATION (Continued from page 10) involved. OFFICERS “All this creates challenges for ISASI 2018 SPONSORS President, Frank Del Gandio an air safety investigator. You are ([email protected]) Executive Advisor, Richard Stone going to have to unravel how we GOLD-PLUS ([email protected]) allowed all this to happen. This also General Civil Aviation Authority, UAE Vice President, Ron Schleede means those new players have to ([email protected]) Emirates Secretary, Chad Balentine understand our world in terms of ([email protected]) how an investigation process puts Treasurer, Robert MacIntosh, Jr. value back into the aviation sys- GOLD ([email protected]) tem. We have done that very well for a long time. But this requires Abu Dhabi Airports COUNCILORS a clear understanding that there Airbus Australian, Richard Sellers ([email protected]) is an independent process, which Boeing Canadian, Barbara Dunn ([email protected]) takes time, and it is not something Embraer European, Rob Carter that you can shortcut,” concluded ([email protected]) Ethiad Airways–Abu Dhabi International, Caj Frostell Braithwaite. ([email protected]) Following the morning technical GE Aviation New Zealand, Alister Buckingham presentations, seminar partici- Ocean Infinity ([email protected]) Pakistan, Wg. Cdr. (Ret.) Naseem Syed pants enjoyed a lunch break. In the Saudia Ahmed ([email protected]) afternoon, Moderator Olivier Fer- United States, Toby Carroll rante, BEA, began introducing the ([email protected]) remaining technical presentations SILVER and the final Kapustin scholarship Lockheed Martin NATIONAL AND REGIONAL winner’s essay. Delegates then USC SOCIETY PRESIDENTS watched a short video about the AsiaSASI, Chan Wing Keong facilities and plans for ISASI 2019 ([email protected]) BRONZE Australian, Richard Sellers to be held in the Hague, the Neth- ([email protected]) erlands, from Sept. 2–6, 2019—in- Air Arabia Canadian, Barbara Dunn ([email protected]) cluding tutorials on Monday and European, Olivier Ferrante Gulfstream ([email protected]) a postseminar optional tour on Parker Korean, Dr. Tachwan Cho (contact: Dr. Jenny Friday. The theme for ISASI 2019 is Yoo—[email protected]) “Has the Past Become Irrelevant?” SCSI Latin American, Guillermo J. Palacia (Mexico) Middle East North Africa, Khalid Al Raisi ISASI 2018 Host Committee ([email protected]) Chairman Tom Curran then passed BOOTH SPONSORS New Zealand, Graham Streatfield the Society’s traditional cowbell to ([email protected]) Aerobytes Ltd. Pakistan, Wg. Cdr. (Ret.) Naseem Syed ISASI 2019 Host Committee CEFA Aviation Ahmed ([email protected]) Chairman Daan Zwart, VNV– Russian, Vsvolod E. Overharov Dutch ALPA. Zwart presented a Cranfield University ([email protected]) United States, Toby Carroll pair of wooden shoes to Del Plane Sciences ([email protected]) Gandio, who then closed the TU Delft University gathering with thanks to everyone UNITED STATES REGIONAL who attended and participated. CHAPTER PRESIDENTS Alaska, Craig Bledsoe ([email protected]) Arizona, Bill Waldock ([email protected]) Dallas-Ft. Worth, Erin Carroll MOVING? NEW E-MAIL ACCOUNT? ([email protected]) Great Lakes, Matthew Kenner Do you have a new mailing address? Have you recently ([email protected]) Mid-Atlantic, Ron Schleede changed your e-mail address? Then contact ISASI at isasi@ ([email protected]) Northeast, Steve Demko erols.com to ensure that your magazine and other ISASI ([email protected]) materials are delivered to you. Please include your previous Northern California, Kevin Darcy ([email protected]) address with your change request. Members in Canada, New Pacific Northwest, (Acting) John Purvis ([email protected]) Zealand, and Australia should contact your national society. Rocky Mountain, David Harper ([email protected])

30 • January-March 2019 ISASI Forum ISASI INFORMATION

Southeastern, Robert Rendzio Air Astana JSC Grup Air Med S.A. ([email protected]) Air Canada Gulfstream Aerospace Corporation Southern California, Thomas Anthony Air Canada Pilots Association Hall & Associates LLC Air Line Pilots Association ([email protected]) Hawaiian Airlines Airbus HNZ New Zealand Limited Airclaims Limited Hogreen Air COMMITTEE CHAIRMEN Air New Zealand Honeywell Aerospace Airways New Zealand Audit, Dr. Michael K. Hynes Hong Kong Airline Pilots Association All Nippon Airways Co., Ltd. (ANA) Human Factors Training Solutions Pty. Ltd ([email protected]) Allianz Independent Pilots Association Award, Gale E. Braden ([email protected]) Allied Pilots Association Insitu, Inc. Ballot Certification, Tom McCarthy Aloft Aviation Consulting Interstate Aviation Committee ([email protected]) Aramco Associated Company Irish Air Corps Board of Fellows, Curt Lewis ([email protected]) Asiana Airlines Irish Aviation Authority Bylaws, Darren T. Gaines ASPA de Mexico Japan Transport Safety Board ASSET Aviation International Pty. Ltd. Jones Day ([email protected]) Association of Professional Flight Attendants Code of Ethics, Jeff Edwards ([email protected]) KLM Royal Dutch Airlines Australian and International Pilots’ Association Korean Air Membership, Tom McCarthy ([email protected]) (AIPA) Korea Aviation & Railway Accident Mentoring Program, Anthony Brickhouse Australian Transport Safety Bureau Investigation Board ([email protected]) Aviation Investigation Bureau, Jeddah, L-3 Aviation Recorders Nominating, Troy Jackson Kingdom of Saudi Arabia Learjet/Bombardier Aerospace ([email protected]) Aviation Safety Council Lion Mentari Airlines, PT Reachout, Glenn Jones ([email protected]) Avisure Lockheed Martin Aeronautics Company Azure Aero Ltd Middle East Airlines Scholarship Committee, Chad Balentine Becker Helicopters Pty. Ltd. ([email protected]) Midwest University Bell Military Air Accident Investigation Branch Seminar, Barbara Dunn ([email protected]) Bundesstelle fur Flugunfalluntersuchung (BFU) Military Aircraft Accident & Incident Bureau d’Enquêtes et d’Analyses (BEA) Investigation Board CAE Flightscape Ministry of Transport, Transport Safety WORKING GROUP CHAIRMEN Cathay Pacific Airways Limited Air Traffic Services, Scott Dunham (Chair) Investigation Bureau, Singapore Centurion Aerospace Ltd. National Aerospace Laboratory, NLR ([email protected]) Charles Taylor Aviation National Institute of Aviation Safety and Ladislav Mika (Co-Chair) ([email protected]) China Airlines Services Airports, David Gleave ([email protected]) Civil Aviation Authority, Macao, China National Transportation Safety Board Cabin Safety, Joann E. Matley Civil Aviation Department Headquarters National Transportation Safety Committee- ([email protected]) Civil Aviation Safety Authority Australia Indonesia (KNKT) Civil Aviation Safety Investigation and Analysis NAV CANADA Corporate Affairs, Erin Carroll Center ([email protected]) Ocean Infinity Colegio Oficial de Pilotos de la Aviación Pakistan Air Force-Institute of Air Safety Critical Incident Stress Management (CISM), Comercial (COPAC) David Rye--([email protected]) Commercial Aircraft Corporation of China Pakistan Airline Pilots’ Association (PALPA) Pakistan International Airlines Corporation (PIA) Flight Recorder, Michael R. Poole Cranfield Safety & Accident Investigation Centre Papua New Guinea Accident Investigation ([email protected]) Commission (PNG AIC) General Aviation, Steve Sparks Curt Lewis & Associates, LLC Dassault Aviation Parker Aerospace ([email protected]) DDAAFS Petroleum Air Services Co-Chair, Doug Cavannah Defence Science and Technology Organisation Phoenix International Inc. ([email protected]) (DSTO) Plane Sciences, Inc., Ottawa, Canada Government Air Safety Facilitator, Defense Conseil International (DCI/IFSA) Pratt & Whitney Marcus Costa ([email protected]) Delft University of Technology PT Merpati Nusantara Airlines Qatar Airways Human Factors, Edma Naddof Delta Air Lines, Inc. Directorate of Flight Safety (Canadian Forces) Republic of Singapore Air Force (RSAF) ([email protected]) Rolls-Royce PLC Investigators Training & Education, Discovery Aur Defence Dombroff Gilmore Jaques & French P.C. Royal Danish Air Force, Tactical Air Command Graham R. Braithwaite DRS C3 & Aviation Company, Avionics Line of Royal Netherlands Air Force ([email protected]) Business Royal New Zealand Air Force Military Air Safety Investigator, James W. Roberts Dubai Air Wing RTI Group, LLC ([email protected]) Dubai Civil Aviation Authority Saudia Airlines-Safety Unmanned Aerial Systems, Tom Farrier Dutch Airline Pilots Association Scandinavian Airlines System Sikorsky Aircraft Corporation ([email protected]) Dutch Safety Board Eclipse Group, Inc. Singapore Airlines Limited Education and Training Center for Aviation SkyTrac Systems Ltd CORPORATE MEMBERS Safety Southwest Airlines Company AAIU, Ministry of Transport EL AL Israel Airlines Southwest Airlines Pilots’ Association Abakan Air Embraer-Empresa Brasileira de Aeronautica Spanish Airline Pilots’ Association (SEPLA) Accident Investigation Board (AIB) Army Aviation S.A. State of Israel Accident Investigation Board Norway Embry-Riddle Aeronautical University Statens haverikommission Accident Investigation Bureau Nigeria Etihad Airways Swiss Accident Investigation Board (SAIB) Administration des Enquêtes Techniques European Aviation Safety Agency (EASA) The Air Group Adnan Zuhairy Engineering Consultancy EVA Airways Corporation The Boeing Company Aegean Airlines Executive Development & Management Advisor The Japanese Aviation Insurance Pool (JAIP) Aer Lingus Finnair Plc Transportation Safety Board of Canada Aero Republica Finnish Military Aviation Authority Turbomeca Aerovias De Mexico, S.A. De C.V. Flight Data Services Ltd. Ukrainian National Bureau of Air Accidents and Agenzia Nazionale Per La Sicurezza Del Volo Flight Data Systems Pty. Ltd. Incidents of Civil Aircraft Air Accident Investigation Authority of Hong Kong Flight Safety Foundation UND Aerospace Air Accident Investigation Bureau of Mongolia Fugro Survey Middle East Ltd. United Airlines Air Accident Investigation Bureau of Singapore Gangseo-gu, Republic of Korea United States Aircraft Insurance Group Accident Investigation Committee of Thailand GE Aviation University of Balamand/Balamand Institute of Air Accident Investigation Unit-Ireland General Aviation Manufacturers Association Aeronautics Air Accident Investigation Sector, GCAA, UAE German Military Aviation Authority, Directorate of University of Southern California Air Accidents Investigation Branch-UK Aviation Safety Federal Armed Forces Virgin Galactic Air Asia Group Global Aerospace, Inc. WestJet January-March 2019 ISASI Forum • 31 ISASI 107 E. Holly Ave., Suite 11 Sterling, VA 20164-5405 USA

INCORPORATED AUGUST 31, 1964 CHANGE SERVICE REQUESTED

ERAU Student Selected for Robertson/ISASI Fellowship

ori Kobayashi, a stu- up close that I had only seen Aviation Safety and Security outsourced aviation mainte- dent at Embry–Riddle in air shows, and it would Archives,” said Kobayashi. “I nance. Aeronautical University give me the experience and drew encouragement from Harry Robertson, an ISASI T(ERAU) in Prescott, maturity I needed to pursue seeing handwritten docu- Fellow and Lederer Award Arizona, USA, was awarded an aviation-related career.” ments by Jerome Lederer, the winner who developed and in November 2018 the Rob- Kobayashi came to ERAU’s ‘Father of Aviation Safety.’ produced the Robertson ertson/ISASI Fellowship in Prescott campus as a veteran Jerome Lederer created the crashworthy fuel system Aviation Safety and Crashwor- of the U.S. Air Force, holder Aircraft Mechanic’s Creed in found in many helicopters thiness. She completed her of an FAA A&P certificate, 1941, which is used globally in and race cars, endowed and B.S. degree in aeronautics in and possessing an associate repair stations and hangars. helped establish the Robert- December 2018 and plans to of science degree in aero- His work has been my biggest son Family/ISASI Aviation continue at ERAU Prescott for nautics from Embry–Riddle inspiration in conducting Safety and Security Fellowship graduate studies. Worldwide. Kobayashi chose research on aviation mainte- to allow graduate students to Originally from Lomita, to come to Prescott to further nance safety culture.” conduct research on crash- California, USA, Kobayashi’s her education with a con- Kobayashi’s planned areas worthy safety topics at ERAU interest in pursuing aviation centration in aviation safety. of research while holding the in Prescott. For more informa- was inspired while attending While at Prescott, Kobayashi Robertson/ISASI Fellowship tion on the fellowship, go to an air show at Edwards Air participated in Women in include human factors and the ISASI Web Roundup Force Base in California. She Aviation International and safety culture in aviation News, May–June 2015, pages was particularly enthused by the ISASI Arizona Chapter at maintenance operations, 3–7, in the Library on ISASI’s the history of Chuck Yeager’s ERAU. In advance of pursuing with a concentration on website. Bell X-1 flight breaking the the fellowship application, sound barrier at Edwards. Kobayashi completed a cap- Upon graduating high school, stone research project titled Kobayashi joined the Air The History of Human Factors Force with the specific goal of in Maintenance. becoming an aircraft main- Kobayashi’s decision to tainer. “I did achieve this in seek the Robertson/ISASI active duty and as a veteran Fellowship was predicated on with my airframe & power- the knowledge and experi- plant [A&P] certificate,” said ence that would come with Kobayashi. “I knew enlisting it. “[It would] provide me ISASI President Frank Del Gandio, left, and Treasurer Bob MacIntosh to be a maintainer would give with the opportunity to work congratulate Tori Kobayashi for being awarded the 2018 Robertson/ me the chance to see aircraft closely with Embry–Riddle’s ISASI Fellowship during a Jan. 8, 2019, luncheon.

32 • January-March 2019 ISASI Forum